Statutory Accident Benefits Schedule matters (SABS)

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

The issues in dispute included entitlement to attendant care benefits, an award for unreasonable delay, interest, and costs.

The adjudicator found the applicant entitled to attendant care benefits at the maximum hourly rate permitted by the Guideline, totaling $745.00, rather than the higher rate claimed.

The claim for an award under s. 10 of Regulation 664 was dismissed, as the insurer's partial payment in accordance with the Guideline was not unreasonable or inflexible.

The respondent's request for costs was also dismissed, as there was no evidence the applicant acted frivolously or vexatiously.

The applicant sought statutory accident benefits following a motor vehicle accident, including an income replacement benefit (IRB) and chiropractic treatment.

The respondent denied the benefits and sought repayment of past IRBs, alleging wilful misrepresentation regarding the applicant's receipt of long-term disability benefits.

The Tribunal found that the applicant failed to prove entitlement to the IRB and chiropractic treatment, as the medical evidence did not establish a substantial inability to perform the essential tasks of his employment or that the treatment was reasonable and necessary.

However, the Tribunal dismissed the respondent's claim for repayment, finding that the overpayment was due to an adjuster error rather than wilful misrepresentation, and the notice of repayment was provided outside the 12-month limitation period.

Claims for interest and a special award were also dismissed.

The applicant sought income replacement benefits, medical benefits, interest, and a special award following a motor vehicle accident.

The Licence Appeal Tribunal dismissed all claims.

The Tribunal found the applicant failed to prove a substantial inability to perform the essential tasks of his employment, noting inconsistencies in his medical records, a failure to report pre-accident income, and persuasive insurer examination reports.

The claims for chiropractic, psychological, and occupational therapy treatment plans were also dismissed because the applicant failed to submit the plans into evidence and did not establish that the treatments were reasonable and necessary.

The applicant sought statutory accident benefits following a motor vehicle accident, disputing the respondent's determination that his injuries fell within the Minor Injury Guideline (MIG).

The applicant claimed his psychological injuries and chronic neck and shoulder pain warranted removal from the MIG.

The Tribunal found insufficient contemporaneous medical evidence to support removal from the MIG, noting the applicant's primary complaints were treated conservatively by his family doctor.

The application for a $2,951.33 chiropractic treatment plan was dismissed as the applicant failed to prove it was reasonable and necessary, and the MIG limits had already been exhausted.

The applicant sought accident benefits following a motor vehicle accident.

The Tribunal found the applicant's injuries fell within the Minor Injury Guideline (MIG), as he failed to establish chronic pain with functional impairment or a psychological impairment.

The applicant was denied an income replacement benefit due to lack of evidence.

However, the Tribunal ordered the respondent to pay for two chiropractic treatment plans because its denial letters failed to provide specific medical reasons as required by section 38(8) of the Schedule.

Claims for other treatment plans and an award under Regulation 664 were dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident, specifically claiming entitlement to physiotherapy services, assistive devices, interest, and an award for unreasonable delay under s. 10 of Regulation 664.

The Licence Appeal Tribunal found that the applicant failed to prove the disputed treatment plans were reasonable and necessary, noting a duplication of services and lack of justification for the assistive devices.

The Tribunal also dismissed the claim for a s. 10 award, finding that the insurer did not act unreasonably in delaying the catastrophic impairment determination until it received the necessary diagnostic imaging reports.

The application was dismissed in its entirety.

The applicant sought a $10,000 death benefit under the Statutory Accident Benefits Schedule following the death of her father in a motor vehicle accident.

The respondent denied the benefit on the basis that the deceased was not an insured person under his father's policy.

The Tribunal found that the applicant failed to prove the deceased was principally dependent on his father or stepmother for financial support or care.

As the deceased was not a dependent, he was not an insured person under the policy, and the applicant was not entitled to the death benefit.

The applicant sought a $10,000 death benefit from the respondent insurer following the death of her father in a motor vehicle accident.

The respondent denied the claim on the basis that the deceased was not an "insured person" under the policy issued to the applicant's mother.

The Tribunal found that the deceased was not a named insured, a specified driver, a spouse of the named insured, or a dependent of the named insured.

As the applicant failed to prove the deceased was an insured person under the respondent's policy, the application for a death benefit was dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident, disputing the respondent's determination that his injuries fell within the Minor Injury Guideline (MIG).

The Tribunal excluded the applicant's late-filed medical records due to non-compliance with production orders.

The Tribunal found insufficient evidence of a concussion, chronic pain, or psychological impairment to warrant removal from the MIG.

The applicant was held to the $3,500 MIG limit and was only entitled to the remaining balance of $458.67 for incurred benefits, plus interest.

The applicant sought statutory accident benefits after falling when the driver of her hired vehicle stepped backwards into her while loading the trunk.

The respondent insurer denied benefits, arguing the incident did not meet the definition of an 'accident' under section 3(1) of the Statutory Accident Benefits Schedule.

The Licence Appeal Tribunal found that the applicant satisfied both the purpose and causation tests, as loading a vehicle is an ordinary use of an automobile and the driver's push was a normal incident of the risk created by such use.

The Tribunal concluded the applicant was involved in an accident and is entitled to proceed with her claim.

The applicant sought a non-earner benefit following a motor vehicle accident but failed to submit a completed disability certificate (OCF-3) until July 21, 2023.

The insurer denied the benefit for the period prior to the submission of the OCF-3.

The Licence Appeal Tribunal held that under section 36 of the Statutory Accident Benefits Schedule, no non-earner benefit is payable for any period before the OCF-3 is submitted.

The application was dismissed.

The applicant sought various statutory accident benefits following a motor vehicle accident, including attendant care, occupational therapy, physiotherapy, chiropractic services, medical cannabis, and psychological services.

The Tribunal denied the claims for attendant care, occupational therapy, and physical therapies, finding the applicant's self-reporting unreliable and noting that physical therapies had previously plateaued without lasting benefit.

However, the Tribunal granted the treatment plans for medical cannabis and psychological services, finding them to be reasonable and necessary untrialed interventions for the applicant's accident-exacerbated chronic pain and adjustment disorder.

The applicant's request for costs was denied.

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

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

The Tribunal found the applicant failed to prove his psychological injuries or insomnia warranted removal from the MIG, noting inconsistencies with treating physician records.

The Tribunal also dismissed the claim for income replacement benefits, finding insufficient evidence of the applicant's essential work tasks or how his injuries impaired his ability to perform them.

All claims for treatment plans, medication, and an award were dismissed.

The applicant was struck by an unidentified vehicle in November 2018 but did not notify the respondent insurer until February 2022.

The respondent denied the claim for accident benefits on the basis that the applicant failed to provide notice within 7 days as required by section 32(1) of the Schedule.

The Tribunal found that the applicant did not have a reasonable explanation for the delay, noting she could have notified the Motor Vehicle Accident Claims Fund much earlier, as she had retained counsel and reported the accident to healthcare providers shortly after it occurred.

The application was dismissed as statute-barred.

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

The insurer denied the benefits, and the applicant applied to the Licence Appeal Tribunal.

The insurer raised a preliminary issue that the application was statute-barred because it was filed beyond the two-year limitation period under section 56 of the Statutory Accident Benefits Schedule.

The Tribunal found that the insurer had issued valid denial notices for all disputed benefits, triggering the limitation periods.

As the application was filed after the limitation periods expired and the applicant provided no submissions to justify an extension, the Tribunal dismissed the application as statute-barred.

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

The insurer raised preliminary issues, arguing the applicant was statute-barred for missing the two-year limitation period and for failing to attend an insurer's examination.

The Tribunal found the application was timely because the limitation period expired on a weekend, extending it to the next business day.

The Tribunal also found the notice of examination was deficient, excusing the applicant's non-attendance.

On the substantive issues, the Tribunal denied the claim for a sleep study assessment but granted the claim for an interdisciplinary chronic pain assessment, finding it reasonable and necessary given the applicant's chronic pain and history of addictions.

Interest was awarded on the overdue payment, but a claim for a special award was dismissed.

The applicant sought statutory accident benefits following a 2018 motor vehicle accident.

The Tribunal found the applicant did not sustain a catastrophic impairment under Criterion 8, as his mental and behavioural impairments were moderate (Class 3) rather than marked (Class 4) in the domains of activities of daily living and social functioning.

However, the Tribunal found the applicant was entitled to a post-104-week income replacement benefit, as his combined physical and psychological impairments resulted in a complete inability to engage in suitable employment.

Claims for occupational therapy and attendant care were dismissed as non-catastrophic funding was exhausted.

The applicant was awarded interest on overdue payments but denied a special award.

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

The insurer denied a treatment plan for chiropractic services, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found that the applicant suffered from an accident-related psychological impairment (PTSD) that warranted removal from the MIG.

The Tribunal also found the proposed chiropractic treatment plan to be reasonable and necessary, ordering the insurer to pay the benefit with interest.

The applicant's claim for an award for unreasonable delay was dismissed.

The defendants brought a Rule 21.01(1)(b) motion to strike a conspiracy claim from a statement of claim alleging fraudulent Statutory Accident Benefits Schedule (SAB) insurance claims.

The plaintiff insurer alleged that the defendants conspired to submit fraudulent invoices for treatment services not rendered and sought damages arising from the payments made.

The court applied the doctrine of merger, holding that where a plaintiff pleads that defendants conspired to commit a fraud and also carried out that fraud, the conspiracy claim merges with the tort of fraud and becomes redundant.

Because the damages alleged were solely attributable to the fraud and not to a stand-alone conspiracy, the conspiracy claim disclosed no independent cause of action.

The conspiracy pleading was struck with leave to amend the claim to clarify that the allegations are grounded in fraud.

The Motor Vehicle Accident Claims Fund appealed an arbitrator’s decision finding that an injured motorcyclist was not principally dependent on his parents for financial support under the Statutory Accident Benefits Schedule.

The arbitrator had concluded that during the 12 months preceding the accident the claimant’s employment income exceeded 51% of his financial needs, applying the dependency framework from Miller v. Safeco and subsequent arbitral jurisprudence.

The appellant argued the arbitrator misapplied the dependency factors and improperly confined the analysis to the year preceding the accident.

The court held that the determination of dependency involved mixed fact and law and was reviewable on a reasonableness standard.

Finding the arbitrator’s use of the 12‑month timeframe and the 51% dependency test reasonable and consistent with established jurisprudence, the court dismissed the appeal.