Statutory Accident Benefits Schedule matters (SABS)

The applicant sought statutory accident benefits following a motor vehicle accident.

The respondent denied the benefits, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The applicant argued for removal from the MIG based on psychological impairments and chronic pain.

The adjudicator found that the applicant failed to provide sufficient medical evidence, such as clinical notes and records, to establish a psychological impairment or chronic pain with functional impairment.

Consequently, the applicant's injuries were deemed predominantly minor, and having exhausted the $3,500 MIG limit, she was not entitled to the disputed treatment plans or interest.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits.

The respondent insurer scheduled orthopaedic and neurological insurer's examinations in Toronto.

The applicant, who resides in Thunder Bay, failed to attend, citing a medical inability to travel.

The respondent suspended benefits and argued the applicant was barred from proceeding with his application.

The Tribunal found that while the respondent made reasonable efforts to schedule the examinations at a convenient location, the applicant had a reasonable excuse for his non-attendance.

Exercising its discretion under section 55(2) of the Schedule, the Tribunal allowed the application to proceed.

The applicant sought statutory accident benefits following a motor vehicle accident.

The respondent denied several treatment plans on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG).

The applicant argued that the respondent failed to provide compliant denial notices under s. 38(8) of the Schedule, which should preclude it from relying on the MIG limit.

The Tribunal found that the applicant failed to prove her injuries warranted removal from the MIG.

Furthermore, the Tribunal held that the respondent's denial notices and notice of examination were compliant with the Schedule, as they provided sufficient medical reasons based on section 44 assessments.

The application was dismissed.

The respondent insurer requested reconsideration of a Licence Appeal Tribunal decision that granted the applicant a 15% special award on dental services, chiropractic services, and prescription eyeglasses.

The Vice-Chair found the adjudicator committed a material breach of procedural fairness by failing to provide sufficient reasons for granting an award on the chiropractic services and eyeglasses.

However, the Vice-Chair upheld the award for the dental services, finding the adjudicator provided adequate reasons based on the insurer's unexplained eight-month delay in payment.

The reconsideration was granted in part, and the decision was varied to limit the 15% award solely to the dental services.

The applicant was sitting in his parked vehicle when he was assaulted by armed assailants attempting to steal his car.

While trying to escape, the applicant put the vehicle in reverse with his leg outside the door, colliding with a dumpster and resulting in the amputation of his leg.

The respondent denied statutory accident benefits on the basis that the incident was an assault, not an accident.

The Tribunal applied the two-part purpose and causation test, finding that reversing the vehicle was an ordinary use of an automobile and was the dominant feature that directly caused the applicant's leg injury.

The Tribunal concluded the incident met the definition of an 'accident' under section 3(1) of the Schedule.

The applicant sought statutory accident benefits following a motor vehicle accident.

The insurer denied benefits, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found the applicant suffered from accident-related chronic pain with functional impairment, warranting removal from the MIG.

The Tribunal awarded the claimed medication expenses as reasonable and necessary for pain management and associated mental health challenges.

However, the claim for chiropractic services was denied due to insufficient evidence of reasonableness and necessity.

No interest was awarded.

The applicant sought entitlement to several treatment plans for physiotherapy, chiropractic, and psychological services following a motor vehicle accident, as well as an award for unreasonable delay.

The Licence Appeal Tribunal dismissed the application, finding that the applicant failed to prove the treatment plans were reasonable and necessary.

The Tribunal preferred the respondent's medical evidence, which indicated that further physical therapy would not provide lasting relief and that the applicant's psychological symptoms did not warrant the requested interventions.

Claims for interest and a special award were also dismissed.

The applicant sought a determination that she sustained a catastrophic impairment under Criterion 7 of the Statutory Accident Benefits Schedule following a motor vehicle accident.

The Tribunal assessed various Whole Person Impairment (WPI) ratings provided by multiple medical experts for physical and psychological impairments, including complex regional pain syndrome, sleep disturbances, and right upper extremity deficits.

The Tribunal rejected several of the applicant's expert ratings for failing to follow the AMA Guides' methodology and lacking objective medical evidence.

Ultimately, the Tribunal calculated a combined WPI rating of 50%, falling short of the 55% threshold required for a catastrophic impairment designation.

The application was dismissed.

The applicant sought entitlement to various statutory accident benefits following a motor vehicle accident, including chiropractic, massage therapy, occupational therapy, speech-language pathology, and assistive devices.

The Tribunal found that the accident exacerbated the applicant's pre-existing right hip osteoarthritis, necessitating a hip replacement.

The Tribunal approved a May 2022 treatment plan for chiropractic and massage therapy, as well as a long-handled tub scrubber, finding them reasonable and necessary.

The remaining treatment plans were denied due to a lack of compelling evidence demonstrating their necessity or because the expenses were incurred prior to the submission of a treatment plan.

The applicant was involved in a motor vehicle accident and sought statutory accident benefits.

She submitted her application for benefits (OCF-1) 10 months after receiving the application package.

The respondent denied benefits and argued the application was statute-barred.

The Tribunal found that the applicant failed to provide a reasonable explanation for the delay, as her reasons regarding her son's health and family bereavements did not adequately explain the 10-month delay.

The application was dismissed pursuant to section 55(1) of the Schedule.

The applicant sought statutory accident benefits, including income replacement benefits (IRBs) and funding for seven physiotherapy treatment plans, following a motor vehicle accident.

The Licence Appeal Tribunal dismissed the application in its entirety.

The adjudicator found the applicant's self-reporting to medical assessors unreliable due to symptom magnification and surveillance evidence showing the applicant working long hours at a restaurant.

Consequently, the applicant failed to prove a substantial inability to perform the essential tasks of his employment for pre-104 week IRBs, or a complete inability to engage in any employment for post-104 week IRBs.

The physiotherapy plans were deemed not reasonable and necessary, as the applicant contemporaneously reported to his family doctor that the treatments were ineffective.

The applicant, a cyclist intentionally struck by a vehicle, sought statutory accident benefits for occupational therapy and chiropractic services, as well as a special award for unreasonable delay.

The Licence Appeal Tribunal partially approved the occupational therapy plan, finding it reasonable and necessary based on a contemporaneous psychiatric report diagnosing severe PTSD and depression.

The chiropractic plan was denied due to a lack of corroborating contemporaneous medical evidence.

The claim for a special award was dismissed as the insurer's denial was not found to be unreasonable.

The applicant sought a determination that he sustained a catastrophic impairment under Criterion 8 (mental or behavioural disorder) following a 2017 motor vehicle accident.

The Tribunal evaluated the four domains of function under the AMA Guides.

Preferring the evidence of the applicant's experts, the Tribunal found the applicant sustained marked impairments in Activities of Daily Living, Concentration, Persistence and Pace, and Adaptation.

As the applicant demonstrated marked impairment in three domains, he met the test for catastrophic impairment.

The claim for a section 10 award was dismissed as no specific benefits were ordered payable.

The respondent insurer requested a reconsideration of a Tribunal decision that barred the applicant from proceeding with his application due to his failure to attend a properly scheduled s. 44 insurer's examination.

The respondent argued the Tribunal erred by failing to also address whether the applicant was barred for failing to dispute the denial of benefits within the two-year limitation period.

The Tribunal dismissed the request, finding that because the application was already barred under s. 55, the limitation period issue was moot and there was no error in declining to rule on it.

The applicant sought statutory accident benefits following a motor vehicle accident, including funding for chiropractic services, a concussion assessment, a psychological assessment, and attendant care assessments.

The insurer denied the treatment plans.

The Tribunal found that the applicant failed to prove on a balance of probabilities that the disputed treatment plans were reasonable and necessary.

The medical evidence indicated the applicant's accident-related injuries were primarily soft tissue strains that had resolved, and her ongoing complaints were attributed to a subsequent fall at home.

The application was dismissed, and claims for interest and a special award were denied.

The applicant sought reconsideration of a decision that terminated her income replacement benefit (IRB) at the 104-week mark.

The applicant argued the adjudicator erred in law by failing to apply section 8(2) of the Statutory Accident Benefits Schedule, which provides that an IRB adjusted for a person turning 65 is payable until death without deductions for post-accident income.

The adjudicator agreed, finding that section 8(2) automatically applies and exempts the applicant from the complete inability test under section 6.

The reconsideration was granted, and the applicant was awarded an ongoing IRB of $4.75 per week.

The applicant sought various statutory accident benefits, including treatment plans and attendant care benefits, following a motor vehicle accident.

At the start of the videoconference hearing, both parties requested to convert the proceeding to a written hearing as they were unprepared to proceed.

The adjudicator denied the request, noting the file's age and proper notice, and ordered a brief recess for preparation.

Following the recess, the parties advised that they had settled all issues in dispute, resulting in the closure of the Tribunal's file.

The applicant was involved in a motor vehicle accident and sought statutory accident benefits.

The insurer denied benefits and argued the applicant was barred from proceeding because he failed to submit the OCF-1 application within the prescribed 30-day time limit.

The Tribunal found that the applicant provided a reasonable explanation for the delay, as the insurer's correspondence regarding the interplay between WSIB benefits and accident benefits was confusing.

Although the applicant was not barred from proceeding, the Tribunal closed the file as there were no substantive issues in dispute.

The applicant sought statutory accident benefits following a motor vehicle accident but was denied by the insurer.

The insurer raised a preliminary issue that the applicant was barred from proceeding under s. 55 of the Schedule for failing to attend requested insurer examinations (IEs) under s. 44.

The Tribunal found that the requested physiatry and psychological IEs were reasonably necessary and that the notice letters complied with the Schedule.

As the applicant failed to attend without a reasonable explanation, her application was dismissed.

However, the Tribunal awarded the applicant $500 in costs due to the insurer's unreasonable conduct in delaying the production of an occupational therapy report.

The applicant was involved in a motor vehicle accident and sought statutory accident benefits.

He notified the insurer of the accident the next day but denied injuries, and did not submit an intention to claim benefits until over six months later.

The insurer denied the claim based on late notice.

The Tribunal found that the applicant failed to comply with the seven-day notice requirement under section 32(1) of the Schedule and failed to provide a reasonable explanation for the delay.

Consequently, the application was dismissed as statute-barred under section 55(1)1.