Statutory Accident Benefits Schedule matters (SABS)

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

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

The Tribunal found that the applicant's injuries were predominantly minor, preferring the respondent's medical evidence which aligned with the clinical notes of the treating family physician and ER records.

The Tribunal gave less weight to the applicant's assessors due to inconsistent self-reporting by the applicant.

As the applicant remained within the MIG, the disputed treatment plans and interest were denied.

The applicant sought statutory accident benefits following an incident where she was assaulted by her husband while driving, causing her to veer off the road and mount a curb.

The Tribunal found that the incident met the definition of an "accident" under s. 3(1) of the Schedule, as the operation of the vehicle was the dominant feature causing her psychological injuries, which exacerbated pre-existing conditions.

Consequently, the applicant's injuries were removed from the Minor Injury Guideline.

However, the applicant's claims for an income replacement benefit, various treatment plans, attendant care benefits, and a special award were dismissed because she failed to provide sufficient medical evidence or establish that the expenses were reasonable, necessary, and incurred.

The applicant sought entitlement to statutory accident benefits for various treatment plans following a motor vehicle accident.

The Licence Appeal Tribunal found that the applicant was entitled to a treatment plan for physiotherapy services aimed at treating post-concussion syndrome, preferring the evidence of the applicant's assessors who conducted in-person and comprehensive evaluations over the respondent's virtual assessment.

However, the Tribunal dismissed the claims for other physiotherapy, chiropractic, massage, exercise therapy, and prescription eyewear, finding insufficient contemporaneous medical evidence to establish that they were reasonable and necessary.

The applicant sought statutory accident benefits after slipping and falling on ice while closing his car door.

The respondent denied the claim, arguing the incident did not meet the definition of an 'accident' under the Schedule.

The Tribunal found that the incident was an accident, as the applicant was actively using his vehicle and the ice was not an intervening event.

The Tribunal also determined that the applicant's fractured elbow removed him from the Minor Injury Guideline.

However, the Tribunal dismissed the claims for an income replacement benefit and specific treatment plans because the applicant failed to provide sufficient medical evidence or copies of the treatment plans to prove entitlement.

The applicant sought non-earner benefits following a September 2022 motor vehicle accident.

The respondent denied the claim, arguing the applicant's impairments stemmed from pre-existing depression and a prior accident in June 2022.

The Tribunal applied the 'but for' causation test and the Heath framework, finding the applicant failed to prove her impairments were caused by the September accident.

The Tribunal preferred the respondent's section 44 assessors, who properly compared the applicant's functioning before and after both accidents, over the applicant's section 25 assessors, who failed to review pre-accident records or account for the prior accident.

The application was dismissed.

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

The Tribunal found that the applicant's chronic pain condition warranted removal from the Minor Injury Guideline (MIG).

However, the applicant's claims for non-earner benefits, a psychological assessment, and a chronic pain assessment were dismissed.

The Tribunal concluded that the applicant did not suffer a complete inability to carry on a normal life, the psychological assessment was not reasonable and necessary, and the chronic pain assessment was duplicative of an OHIP-funded assessment.

Claims for interest and an award were also dismissed.

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

The respondent insurer denied several treatment plans, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found that the applicant failed to provide compelling medical evidence to warrant removal from the MIG, as her physical and psychological injuries were predominantly minor.

However, the Tribunal ordered the respondent to pay for four of the disputed treatment plans because the respondent's denial notices failed to comply with the requirements of s. 38(8) of the Schedule, lacking specific medical reasons or details about the applicant's condition.

The remaining treatment plans were denied, and interest was awarded on the overdue benefits.

The applicant sought an income replacement benefit (IRB) following a motor vehicle accident.

The respondent denied the benefit and raised a preliminary issue that the applicant failed to submit a completed disability certificate (OCF-3) within 104 weeks of the accident.

The Tribunal found that the OCF-3 was not submitted until 240 weeks after the accident.

Applying the Statutory Accident Benefits Schedule, the Tribunal held that the failure to submit the OCF-3 within the 104-week period barred the claim.

The application was dismissed.

The applicant sought a determination that she sustained a catastrophic impairment and was entitled to attendant care benefits following a motor vehicle accident.

The Tribunal found that the applicant did not sustain a catastrophic impairment, as her psychological and physical impairments did not meet the threshold of three or more marked impairments under Criterion 8.

The Tribunal also denied the claim for attendant care benefits, finding that the applicant failed to prove her spouse suffered an economic loss to provide the care, and therefore the expenses were not incurred.

Claims for interest and a special award were also dismissed.

The applicant sought statutory accident benefits following a 2019 motor vehicle accident.

The respondent insurer denied benefits and argued the applicant was barred from proceeding to the Tribunal because she failed to submit an application for benefits (OCF-1) within 30 days of receiving the forms, as required by section 32(5) of the Schedule.

The applicant claimed she had submitted the form and alternatively argued her pre-existing brain injury provided a reasonable explanation for any delay.

The Tribunal found the applicant's explanation was not credible, noting a further six-month delay in submitting the OCF-1 even after she retained counsel and was explicitly advised the form was missing.

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

The applicant sought an income replacement benefit (IRB) following a motor vehicle accident, claiming physical and psychological impairments prevented her from working.

The Tribunal reviewed conflicting medical assessments and found the applicant's presentation of pain and limitation to be inconsistent and lacking full effort.

Preferring the respondent's medical evidence, the Tribunal concluded the applicant did not suffer a substantial inability to perform the essential tasks of her employment.

The application for IRBs, interest, and a special award was dismissed.

The applicant was injured in a motor vehicle accident and sought payment for three treatment plans for psychological services.

The insurer approved the plans but disputed the 1.5-hour session length, arguing for 1-hour sessions.

The Tribunal found the 1.5-hour sessions reasonable and necessary, noting that both the treating psychologist and the insurer's assessor agreed the applicant was improving and needed additional sessions.

The Tribunal ordered payment of the disputed balances and interest, but denied the applicant's request for a special award, finding the insurer did not act unreasonably in questioning the session length.

The applicant sought statutory accident benefits for chiropractic and massage services, a physiatry assessment, and a chronic pain assessment following a 2015 motor vehicle accident.

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

The Tribunal noted a significant gap of over three years where the applicant did not report accident-related pain to his physicians, breaking the causal link to the accident.

Claims for interest and a special award were also dismissed.

The applicant requested a reconsideration of a preliminary issue decision which found his claim for Income Replacement Benefits (IRBs) was statute-barred.

The applicant argued the adjudicator erred in finding the insurer's denial letter was clear and unequivocal, and in refusing to extend the limitation period under section 7 of the Licence Appeal Tribunal Act.

The Tribunal dismissed the request, finding the applicant was attempting to relitigate the initial decision and failed to establish any errors of law or fact that would have changed the outcome.

The Tribunal also rejected the applicant's attempt to introduce an undated resignation letter as new evidence.

The applicant sought entitlement to statutory accident benefits following a motor vehicle accident, including multiple treatment plans for physiotherapy, chiropractic, and psychological services, as well as attendant care benefits.

The Licence Appeal Tribunal dismissed the application, finding that the applicant failed to prove on a balance of probabilities that the disputed treatment plans and attendant care expenses were reasonable and necessary.

The Tribunal preferred the evidence of the respondent's independent examiners over the applicant's assessors and noted the applicant's failure to provide requested information to the insurer.

Claims for interest and an award under s. 10 of Reg. 664 were also dismissed.

The applicant sought entitlement to several medical and rehabilitation assessment plans following a motor vehicle accident.

The applicant's submissions focused entirely on the insurer's alleged failure to comply with response obligations under section 38 of the Schedule, rather than the medical merits of the claims.

The adjudicator found that the applicant breached the Tribunal's page limit order by appending substantive submissions as an exhibit.

The adjudicator excluded the appended submissions and concluded that the insurer had provided compliant denials.

The application was dismissed as the applicant failed to meet her onus to demonstrate entitlement to the benefits.

The applicant sought a determination that she was catastrophically impaired under Criterions 7 and 8 of the Statutory Accident Benefits Schedule following a 2017 motor vehicle accident, along with payment for disputed treatment and assessment plans.

The Tribunal found that the applicant's expert on visual impairment failed to follow the AMA Guides' testing methods, resulting in the rejection of the 24% WPI rating for diplopia.

The Tribunal also adjusted the applicant's psychological impairment ratings, finding them inconsistent with her demonstrated functional abilities.

Consequently, the applicant did not meet the threshold for catastrophic impairment under either criterion.

The claims for psychological services and catastrophic impairment assessments were dismissed for lack of evidence demonstrating they were reasonable and necessary.

The respondent's request for costs due to the applicant's late withdrawal of Criterion 4 was also dismissed.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for a cognitive communication assessment and psychological services.

The respondent denied the assessment and partially approved the psychological services at a lower hourly rate.

The Tribunal found the cognitive communication assessment was reasonable and necessary based on contemporaneous medical evidence of cognitive symptoms.

For the psychological services, the Tribunal found an hourly rate of $130.00 was reasonable for a registered psychotherapist providing cognitive behavioural therapy under the supervision of a psychologist.

The Tribunal also approved preparation fees but denied brokerage and documentation support fees.

The applicant was injured in a bicycle/motor vehicle collision and sought attendant care benefits and an award for unreasonably delayed treatment plans.

The Tribunal found the applicant was not entitled to attendant care benefits as she had regained independence in her activities of daily living.

However, the Tribunal found the insurer unreasonably delayed approving four treatment plans by keeping the applicant in the Minor Injury Guideline despite receiving a neurologist's report diagnosing a concussion.

The Tribunal awarded 25% of the value of the delayed plans ($2,657.54) plus interest.

The applicant requested a reconsideration of a previous Tribunal decision that denied his claim for an income replacement benefit.

The applicant argued that the Tribunal committed a breach of procedural fairness regarding interpretation services, made errors of fact regarding his self-employment income and travel, and failed to consider new evidence regarding his business ownership.

The Tribunal dismissed the request, finding that procedural fairness was maintained, the minor factual error regarding his 2020 tax income would not have changed the outcome, and the new evidence was previously obtainable and immaterial.