Statutory Accident Benefits Schedule matters (SABS)

The applicant sought statutory accident benefits following a motor vehicle accident, claiming catastrophic impairment.

At the hearing, the applicant did not appear, and her counsel made an oral request for an adjournment, citing newly discovered concerns about the applicant's capacity to instruct counsel.

The adjudicator denied the adjournment request, noting that counsel was retained by the applicant's mother acting as litigation guardian, making the capacity issues foreseeable, and that insufficient medical evidence was provided to support the request.

As the applicant filed no evidence and made no submissions to meet her burden of proof, the application was dismissed.

The applicant sought post-104-week income replacement benefits following a motor vehicle accident.

The respondent initially approved the benefits but denied them four days later based on the same Insurer's Examination reports.

The Tribunal found that the respondent's denial was a correction of the initial approval and that the applicant failed to prove a complete inability to engage in any employment for which he was reasonably suited.

The applicant's expert reports were given little weight due to a lack of objective testing and failure to outline functional limitations.

The claim for income replacement benefits and interest was dismissed.

However, the Tribunal awarded the applicant $500 in costs because the respondent breached a case conference report and order by producing documents 137 days late, which interfered with the efficiency of the dispute resolution process.

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

The insurer denied the benefits and scheduled insurer's examinations under section 44 of the Schedule.

The applicant failed to attend the scheduled examinations and did not provide submissions for the preliminary issue hearing.

The Tribunal found that the insurer's notices of examination were compliant with the Schedule and provided adequate reasons.

Consequently, pursuant to section 55 of the Schedule, the applicant was barred from proceeding with his application for benefits.

The applicant sought Non-Earner Benefits (NEBs) following a motor vehicle accident.

The respondent insurer denied the NEBs on the basis that the applicant qualified for Income Replacement Benefits (IRBs).

The applicant filed an application to the Licence Appeal Tribunal nearly three years after the two-year limitation period expired.

The Tribunal found that the respondent's denial was clear and unequivocal, triggering the limitation period under s. 56 of the Statutory Accident Benefits Schedule.

The Tribunal declined to extend the limitation period under s. 7 of the Licence Appeal Tribunal Act, finding no reasonable grounds for the delay.

The application was dismissed as statute-barred.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for psychological and chiropractic treatment plans.

The insurer denied the benefits.

The Tribunal found the applicant was entitled to the psychological assessment and the October 2020 chiropractic treatment plan, as they were reasonable and necessary to address impairments resulting from the accident.

However, the Tribunal dismissed the claims for the 2022 chiropractic treatment plans due to insufficient evidence of their necessity and effectiveness.

The applicant was awarded interest on the overdue payments but denied an award under s. 10 of Reg. 664 as the insurer's actions were not unreasonable.

The applicant insurer sought repayment of $30,112.00 in income replacement benefits (IRBs) paid to the respondent insured, alleging she wilfully misrepresented her post-accident employment status.

The Tribunal found that the respondent was employed and received Employment Insurance benefits during the period she collected IRBs, and that she deliberately failed to disclose this income to the insurer.

Concluding that the respondent wilfully misrepresented her employment status, the Tribunal ordered her to repay $30,016.00 in IRBs to the applicant.

The applicant, who has pre-existing global developmental delay, autism spectrum disorder, and a seizure disorder, sought $3,528.83 for home modifications following a motor vehicle accident.

The applicant argued the accident worsened his seizures and aggressive behaviours, necessitating the modifications.

The Licence Appeal Tribunal dismissed the application, finding the applicant failed to prove on a balance of probabilities that the accident caused an exacerbation of his pre-existing impairments.

The adjudicator noted significant inconsistencies between the grandparents' subjective reports of worsened behaviour and contemporaneous pre-accident medical records, and preferred the respondent's medical evidence that the accident did not cause the reported deterioration.

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

The adjudicator found the applicant was barred from pursuing a non-earner benefit because he failed to prove he submitted a disability certificate (OCF-3) within the limitation period.

The applicant was also barred from pursuing three treatment plans because he failed to attend reasonably necessary insurer's examinations without a reasonable explanation.

On the substantive issues, the adjudicator held the applicant's injuries fell within the Minor Injury Guideline (MIG), denying a proposed physiotherapy treatment plan for lack of reasonableness and necessity.

Claims for an award and interest were also dismissed.

The applicant was injured in a motor vehicle accident and sought medical and rehabilitation benefits under the Statutory Accident Benefits Schedule.

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

The applicant argued that the respondent's denial notices were non-compliant with s. 38(8) and s. 44(5) of the Schedule, and therefore the treatment plans should be payable.

The Tribunal found that the respondent's denial notices provided clear and sufficient medical reasons by stating the injuries were predominantly minor and fell within the MIG.

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

The application was dismissed.

The applicant requested a reconsideration of a Licence Appeal Tribunal decision that denied her entitlement to a non-earner benefit and interest following a motor vehicle accident.

The applicant argued that the adjudicator erred in law and fact by failing to properly apply the Heath test and compare her pre- and post-accident activities, and sought to introduce new evidence including medical reports and her ODSP file.

The Tribunal dismissed the request, finding no error of law or fact, as the original decision properly assessed causation and the applicant's failure to meet her burden of proof regarding her activities between two successive accidents.

Furthermore, the Tribunal held that the proposed new evidence either could have been obtained previously or would not have likely affected the outcome of the hearing.

The applicant sought a non-earner benefit, an award, and interest following a motor vehicle accident.

The adjudicator drew an adverse inference against the applicant for failing to produce ordered medical and employment records without explanation.

Relying on the respondent's medical assessments, the adjudicator found that the applicant did not suffer a complete inability to carry on a normal life, as he remained independent with self-care, household tasks, and his studies.

The application was dismissed, and claims for an award and interest were denied as no benefits were owed.

The applicant sought non-earner benefits (NEBs) following a motor vehicle accident.

The respondent insurer denied the benefits.

The applicant applied to the Licence Appeal Tribunal, arguing she met the test for NEBs and that the respondent's denial letter did not comply with section 36 of the Statutory Accident Benefits Schedule.

The Tribunal found the applicant's medical evidence, including an OCF-3 and clinical notes, lacked sufficient detail to demonstrate a complete inability to carry on a normal life under the Heath test.

The Tribunal also held that the respondent's denial letter sufficiently addressed the applicant's medical condition and complied with section 36(4).

The application was dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident, specifically claiming the unapproved portions of several treatment plans for psychological and occupational therapy services.

The respondent had partially approved the plans but denied the higher hourly rate proposed for a psychotherapist and the costs for brokerage services.

The Tribunal found that the applicant failed to demonstrate why the psychotherapist should be paid at a rate equivalent to a psychologist, exceeding the Professional Services Guideline.

Furthermore, the applicant provided no evidence to justify the brokerage services, which are excluded under the Guideline.

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

The applicant sought payment for various treatment plans, including occupational therapy, psychological and orthopaedic assessments, and workplace modification devices, following a motor vehicle accident.

The Licence Appeal Tribunal found that the applicant failed to establish on a balance of probabilities that the proposed treatment plans were reasonable and necessary.

Medical evidence indicated the applicant had reached functional recovery and returned to pre-accident activities without accommodations.

The application was dismissed.

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 contended she suffered a concussion and chronic pain with functional impairment, warranting removal from the MIG.

The Tribunal found insufficient medical evidence to support a concussion diagnosis or chronic pain with functional impairment, noting the family doctor's records primarily indicated whiplash.

The Tribunal concluded the applicant's injuries were predominantly minor and subject to the MIG limits.

Consequently, the disputed treatment plan for occupational therapy and the claim for interest were dismissed.

The applicant applied for statutory accident benefits following a motor vehicle accident, disputing the respondent's determination that their injuries fell within the Minor Injury Guideline and seeking income replacement benefits and a treatment plan.

The matter was scheduled for a written hearing.

The applicant failed to file any written submissions or evidence by the deadline.

The Tribunal proceeded with the hearing pursuant to s. 7(2) of the Statutory Powers Procedure Act.

As the applicant bore the onus of proof and provided no evidence, the Tribunal found the applicant failed to demonstrate entitlement to the disputed benefits.

The application was dismissed.

The applicant requested a reconsideration of a Licence Appeal Tribunal decision which found she was not catastrophically impaired and denied her claims for attendant care, treatment plans, housekeeping, and costs.

The applicant argued the Tribunal breached procedural fairness and made errors of fact and law in assessing various Whole Person Impairment (WPI) ratings, including those for upper extremity, mental status, diplopia, medications, and social functioning.

The Adjudicator dismissed the request, finding no material breach of procedural fairness as the applicant had ample opportunity to present her case during the 11-day hearing.

Furthermore, the Adjudicator concluded that no errors of fact or law were made that would have resulted in a different outcome.

The applicant was involved in a motor vehicle accident in Quebec and elected to receive benefits under Quebec's Automobile Insurance Act.

He applied to the Licence Appeal Tribunal for an income replacement indemnity and an award for unreasonable delay.

The Tribunal dismissed the application, finding that the applicant failed to adduce compelling medical evidence demonstrating that the accident caused him to be unable to hold employment.

As no benefits were payable, the claims for interest and an award were also dismissed.

The appellants appealed a motion judge's decision dismissing their action against the respondent insurance company for denial of accident benefits.

The action was commenced on August 25, 2015, more than two years after the respondent's final denial of benefits on January 29, 2013.

The Court of Appeal upheld the motion judge's conclusion that the action was statute barred under the applicable limitation period.

The appellants' assertion of bias against the motion judge was rejected as having no merit on the record.

This appeal concerns a dispute between two insurers regarding the payment of statutory accident benefits (SABS) to an injured claimant.

The central issue is whether an insurer's failure to notify the claimant of a priority dispute between insurers within 90 days of receiving the SABS application precluded the insurer from pursuing the dispute.

The arbitrator determined that while notice to the claimant was mandatory, no specific time limit was prescribed by regulation.

The Superior Court reversed this decision, applying a correctness standard of review.

The Court of Appeal allowed the appeal, holding that the reasonableness standard of review applies to arbitrator decisions on SABS priority disputes, even where questions of law are engaged.

The arbitrator's interpretation that late notice did not bar the priority dispute was reasonable.