Statutory Accident Benefits Schedule matters (SABS)

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

The applicant argued he suffered from chronic pain and a psychological condition warranting removal from the MIG, and that the insurer's denial of a physiotherapy treatment plan was non-compliant with s. 38(8) of the Schedule.

The adjudicator found the applicant failed to meet the AMA Guides criteria for chronic pain and lacked evidence of a psychological condition.

The adjudicator also found the insurer's denial letter compliant.

The insurer's claim for repayment of an alleged Income Replacement Benefit overpayment was dismissed due to lack of evidence.

All claims were dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident, claiming his injuries, including major depression and adjustment disorder with anxiety, warranted removal from the Minor Injury Guideline (MIG).

The adjudicator found the applicant did not meet his burden to prove a psychological impairment, placing less weight on the applicant's psychological assessment due to a lack of objective testing and preferring the respondent's psychological assessment which found no accident-related impairment.

As the applicant remained subject to the MIG, the disputed treatment plans for physiotherapy were not considered, and the application was dismissed.

The applicant sought retroactive housekeeping benefits following a motor vehicle accident.

The respondent argued the application was barred by res judicata and the two-year limitation period, as a previous Tribunal decision denying these benefits had been quashed by the Divisional Court on consent, but the consent order only explicitly remitted the issue of attendant care benefits.

The Tribunal found that because the prior decision was quashed in its entirety, there was no final decision on housekeeping benefits, meaning res judicata did not apply.

The Tribunal also found the limitation period was met because the original claim was filed within two years of the denial and preserved despite the quashing.

The preliminary issues were dismissed, and the matter was allowed to proceed to a hearing, with the issue of costs added.

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

The applicant argued for removal from the MIG based on chronic pain and psychological impairment, relying on an orthopedic assessment.

The Tribunal found the applicant did not meet the burden of proof, assigning more weight to the insurer's examinations which found normal physical limits and no functional impairment.

The Tribunal also dismissed the claim for a non-earner benefit, finding the applicant returned to school and managed job responsibilities, failing to demonstrate a complete inability to carry on a normal life.

The application was dismissed.

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

The respondent denied the benefits, and the applicant applied to the Licence Appeal Tribunal four years after the final denial letter.

The preliminary issue was whether the application was statute-barred for failing to comply with the two-year limitation period under section 56 of the Schedule.

The Tribunal found that the respondent's denial letters were clear and compliant with the requirements set out in Smith, thereby triggering the limitation period.

Applying the Manuel factors, the Tribunal concluded there were no reasonable grounds to extend the limitation period under section 7 of the LAT Act, noting the significant delay and lack of a bona fide intention to appeal.

The application was dismissed as statute-barred.

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

The respondent denied a treatment plan for chiropractic services and argued the applicant was subject to the Minor Injury Guideline (MIG).

The Tribunal found the applicant was no longer subject to the MIG.

The Tribunal also held that the respondent's denial notice for the chiropractic treatment plan was defective because it lacked specific medical reasons, triggering the 'shall pay' provision under s. 38(11) of the Schedule.

The applicant was awarded the treatment plan costs once incurred, plus interest, but the claim for a special award was dismissed.

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

The applicant applied to the Licence Appeal Tribunal to dispute the denial of several treatment plans for physiotherapy and assessments, arguing the denial letters were non-compliant with s. 38(8) of the Schedule.

The Tribunal found that the applicant failed to meet the burden of proving her injuries warranted removal from the Minor Injury Guideline (MIG).

Furthermore, the Tribunal held that the respondent's denial letters were compliant with the Schedule, as they clearly identified the treatment plans, stated what would not be paid for, and provided the medical reason that the injuries fell within the MIG.

The application was dismissed.

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

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

The Tribunal found that the applicant failed to provide sufficient medical evidence to prove his injuries extended beyond sprains and strains or that he suffered from chronic pain with a functional limitation.

Consequently, the applicant remained subject to the MIG and was not entitled to the disputed treatment plans, interest, or an award.

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

The respondent denied treatment plans for a chronic pain assessment and chiropractic services.

The Tribunal found the chronic pain assessment reasonable and necessary, noting the applicant's persistent pain complaints and the lack of treatment while incarcerated.

The Tribunal gave limited weight to the respondent's medical examination report due to its lack of analysis and failure to review treating physician records.

However, the Tribunal denied the chiropractic services plan as it lacked support from the applicant's treating practitioners.

The claim for an award under s. 10 of Reg. 664 was dismissed as no submissions were provided.

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

The Tribunal found that the applicant sustained a psychological condition as a result of the accident, warranting removal from the Minor Injury Guideline (MIG).

The applicant was denied funding for five chiropractic treatment plans and a psychological assessment due to insufficient evidence.

However, the Tribunal approved a treatment plan for a chronic pain assessment, finding reasonable grounds based on family doctor records.

The applicant was awarded interest on overdue benefits but denied a special award under s. 10 of Reg. 664.

The applicant requested a reconsideration of a Tribunal decision that found he remained within the Minor Injury Guideline (MIG) and was not entitled to disputed treatment plans.

The applicant argued the adjudicator erred in fact and law by failing to find he suffered a neurocognitive disorder or psychological impairment, and sought to introduce new evidence of a concussion.

The Tribunal dismissed the request, finding the applicant was attempting to re-litigate the case and re-weigh evidence.

The Tribunal held that the adjudicator provided comprehensive reasons for rejecting the applicant's evidence, and the new evidence did not meet the test for reconsideration.

The applicant sought statutory accident benefits following a motor vehicle accident, claiming entitlement to a chiropractic treatment plan and the unapproved portions of four psychological treatment plans.

The Tribunal found that the applicant failed to meet the burden of proving the treatments were reasonable and necessary, noting a lack of supporting medical evidence and a failure to address the insurer's reasons for partial denials.

The Tribunal also held that the insurer's denial notices complied with s. 38(8) of the Schedule.

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

The applicant sought various medical and rehabilitation benefits following a 2020 motor vehicle accident.

The adjudicator found the applicant was not subject to the Minor Injury Guideline, as the insurer had previously removed her from it.

The applicant was awarded a chronic pain assessment based on her family doctor's records, and the balance of a mental health assessment due to a non-compliant denial notice by the insurer.

Claims for psychological, physiatry, and neurological assessments were dismissed, as was the claim for a special award under s. 10 of Regulation 664.

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 chronic pain and a psychological condition.

The Tribunal found insufficient contemporaneous medical evidence to support a diagnosis of chronic pain with functional impairment or a psychological condition beyond normal psycho-social sequelae.

The Tribunal concluded the applicant's injuries were subject to the MIG limit, making it unnecessary to assess the disputed treatment plans, and denied the claim for interest.

The applicant sought statutory accident benefits after falling on a TTC bus due to sudden acceleration.

The respondent denied benefits, arguing the incident did not involve a collision as required by s. 268(1.1) of the Insurance Act for public transit vehicles.

The Tribunal reviewed video evidence and found the bus did not collide with any object, including a manhole cover as alleged by the applicant.

The application was dismissed as the applicant was barred from receiving benefits under the public transit exception.

The applicant sought a determination that he sustained a catastrophic impairment following a motor vehicle accident, relying on Criteria 7 and 8 of the Statutory Accident Benefits Schedule.

The Licence Appeal Tribunal dismissed the application, finding the applicant did not meet the 55% whole-person impairment threshold under Criterion 7 or demonstrate three marked impairments under Criterion 8.

The Tribunal gave no weight to the reports of the applicant's medical experts who failed to attend the hearing for cross-examination, and preferred the evidence of the respondent's assessors, which showed only mild physical and psychological impairments.

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

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

The Tribunal found that the applicant suffered from accident-related psychological impairments, including PTSD and depression, which removed him from the MIG.

Because the insurer's denials were based solely on the MIG, and an insurer cannot split the determination once an insured is removed from the MIG, the Tribunal ordered payment of the disputed physiotherapy and psychological treatment plans.

A claim for prescription expenses was denied for lack of evidence.

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) and that she did not meet the test for a non-earner benefit.

The Tribunal found the applicant failed to discharge her evidentiary burden to prove her injuries warranted removal from the MIG.

The Tribunal also upheld the respondent's denial notices as compliant with the Schedule and dismissed the claims for treatment plans, non-earner benefits, and an award for unreasonable delay.

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

The respondent denied benefits, arguing the applicant was in the course of employment and therefore required to pursue WSIB benefits under s. 61(1) of the Schedule.

The applicant claimed he was an independent contractor and that he elected to pursue a tort action under s. 30 of the WSIA, triggering the exception in s. 61(2).

The Tribunal drew an adverse inference against the applicant for failing to produce employment and WSIB records.

The Tribunal found the applicant had access to WSIB benefits and failed to prove a bona fide intention to pursue a tort claim, as a tort action was barred under s. 28(1) of the WSIA because both vehicles were Schedule 1 employers.

The application was dismissed as statute-barred.

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

The respondent denied the benefits, arguing the applicant was statute-barred for submitting her application seven months late and that her injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found the applicant had a reasonable explanation for the delay due to documented cognitive and psychological challenges.

However, on the substantive issues, the Tribunal concluded the applicant failed to establish that her chronic pain and psychological impairments were caused by the accident rather than pre-existing conditions.

The application for removal from the MIG, non-earner benefits, and treatment plans was dismissed.