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 Tribunal found that the applicant failed to provide persuasive medical evidence to support removal from the MIG.

Consequently, the disputed treatment plans were denied.

The Tribunal also dismissed the claim for income replacement benefits, finding the applicant failed to provide evidence of accident-related functional impairments preventing him from working.

Claims for interest and an award were also dismissed.

The applicant requested reconsideration of a Tribunal decision that found it lacked jurisdiction to determine entitlement to a non-earner benefit because the applicant had not submitted a completed disability certificate (OCF-3).

The applicant argued that the respondent's delay in providing the application forms constituted a reasonable explanation for the delay, and that requiring the form years later was futile.

The Tribunal dismissed the reconsideration request, finding that while the delay explained the late filing, it did not excuse the ongoing failure to submit the mandatory OCF-3 once the forms were received.

As there was no completed application or denial, the Tribunal correctly concluded it had no jurisdiction under s. 280 of the Insurance Act.

The applicant sought accident benefits following a motor vehicle accident, claiming removal from the Minor Injury Guideline (MIG) due to physical injuries, a psychological impairment, and chronic pain.

The adjudicator found insufficient evidence to support removal from the MIG, preferring the respondent's psychological assessment over the applicant's because it was based on clinical testing and medical records rather than solely self-reported data.

The applicant also failed to establish a functional impairment from chronic pain.

The application for a psychological assessment, interest, and a section 10 award was dismissed.

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

The respondent denied the claim for catastrophic impairment and scheduled insurer's examinations (IEs).

The respondent alleged the applicant failed to attend rescheduled IEs and sought to dismiss the application as a preliminary issue.

The Tribunal found the respondent's allegation was pre-emptive and speculative, as there was no evidence the applicant failed to attend the most recently scheduled IEs.

The Tribunal held the respondent did not meet its burden to show non-attendance, and ordered the parties to proceed to the substantive hearing.

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

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

The applicant applied to the Licence Appeal Tribunal for various treatment plans, including psychological and chronic pain assessments, and physiotherapy.

The Tribunal found that the applicant failed to meet the onus of proving his injuries warranted removal from the MIG.

The applicant provided minimal evidence of chronic pain causing functional impairment, no evidence of a pre-existing condition precluding recovery, and no objective evidence of a psychological injury.

Consequently, the applicant remained subject to the $3,500 MIG limit, and the application was dismissed.

The applicant sought entitlement to various treatment plans for chiropractic services, yoga therapy, assistive devices, and a nutritional assessment following a motor vehicle accident.

The Licence Appeal Tribunal dismissed the application, finding that the applicant failed to meet his evidentiary burden.

Specifically, the applicant failed to provide copies of the disputed treatment plans, making it impossible to determine the exact services, goals, and costs proposed.

The Tribunal also found insufficient medical evidence to support the reasonableness and necessity of the claimed benefits.

Claims for interest and a special award were consequently 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 claimed chronic pain and psychological injuries warranted removal from the MIG.

The Tribunal found the medical evidence did not support the applicant's claims of chronic pain with functional impairment or psychological injury.

The applicant was held within the MIG, and the disputed treatment plans, award, and interest were denied.

The respondent insurer requested a reconsideration of a Tribunal decision that ordered payment of disputed treatment plans due to defective denial notices under s. 38(8) of the Schedule.

The insurer argued the Tribunal breached procedural fairness by relying on un-cited binding case law, and erred in law by not applying the 260-week limitation period under s. 20(1)(a) to the s. 38(11) remedy.

The Tribunal dismissed the request, finding no breach of procedural fairness as parties are expected to know binding law, and holding that the consumer protection mandate of the Schedule dictates that s. 20(1)(a) does not constrain the specific remedial provisions of s. 38(11).

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

The Tribunal found that the Applicant was barred from disputing several treatment plans because she failed to apply within the two-year limitation period, noting the insurer's denials were compliant with the requirements in Smith v. Co-operators.

For the remaining treatment plans, the Tribunal dismissed the claims, finding the Applicant failed to provide contemporaneous medical evidence demonstrating that the proposed multidisciplinary, neurological, physiotherapy, and psychological treatments were reasonable and necessary.

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 matter proceeded to a written hearing, but the applicant failed to file any submissions or evidence after her representative withdrew.

The Tribunal found the applicant failed to meet her burden to prove her injuries warranted removal from the MIG or that she was entitled to the disputed treatment plans.

Additionally, the Tribunal ordered the applicant to repay $400.00 in income replacement benefits, as she had returned to work during the period for which the benefits were paid and the respondent had provided proper notice of the overpayment.

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 Tribunal found that the applicant demonstrated chronic pain syndrome with functional impairment, warranting removal from the MIG.

The Tribunal approved the disputed treatment plans for physiotherapy and a psychological assessment, finding them reasonable and necessary based on the medical evidence.

The claim for a special award under s. 10 of Reg. 664 was dismissed as the respondent's conduct did not rise to the level of being unreasonable, but interest was awarded on overdue payments.

The applicant sought entitlement to various treatment plans for home devices, a sleep system, workplace modifications, and kitchen devices following a motor vehicle accident.

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

The Tribunal assigned little weight to the applicant's occupational therapist's recommendations due to a lack of contemporaneous assessment and failure to account for a subsequent accident.

Conversely, the Tribunal accepted the contemporaneous insurer's examination reports which concluded the treatments were not required.

Claims for interest and a special award were also dismissed.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for a concussion assessment and a physiotherapy treatment program.

The respondent insurer denied the benefits based on an insurer's examination report.

The Tribunal found the applicant's medical evidence, including assessments from a psychologist, a chronic pain physician, and a concussion management physiotherapist, outweighed the respondent's general practitioner report, which lacked specific concussion testing.

The Tribunal ordered the respondent to pay for the disputed treatment plans and interest on overdue payments.

However, the Tribunal dismissed the applicant's claim for a special award, finding the respondent's reliance on its medical reports was not unreasonable or arbitrary.

The applicant was injured in a motor vehicle accident and sought $1,524.00 for a chiropractic treatment plan.

The respondent insurer denied the benefit, relying on an insurer's examination which concluded the applicant had reached maximum medical improvement.

The Tribunal found the treatment plan reasonable and necessary, placing less weight on the insurer's examination as it was inconsistent with diagnostic imaging and the longitudinal clinical record showing ongoing shoulder and chest impairments.

The applicant was awarded the cost of the treatment plan.

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

The applicant sought funding for physiotherapy and a psychological assessment.

The Tribunal found that the applicant failed to provide sufficient medical evidence or submissions to demonstrate that his injuries, including alleged chronic pain and psychological conditions, warranted removal from the MIG.

As the applicant was held to the MIG limit, the disputed treatment plans were not analyzed for reasonableness and necessity.

The application was dismissed.

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

The respondent insurer denied benefits, arguing the application was delayed without a reasonable explanation.

The Tribunal found that the applicant, being seven years old at the time of the accident and reliant on her parents, had a reasonable explanation for the delay.

The Tribunal noted the applicant's minority status, her parents' language barriers, and the lack of significant prejudice to the insurer.

The applicant was permitted to proceed with her claim.

The applicant, a resident of China who sustained a severe traumatic brain injury in a motorcoach collision in Ontario, sought court approval for the settlement of her Statutory Accident Benefits Schedule (SABS) claim.

The court dispensed with the requirement for the litigation guardian to file an affidavit, finding it cost-effective and proportionate.

The court approved the SABS settlement of $626,074.11 as reasonable and in the applicant's best interests.

The court also approved the solicitor-client account, the distribution of funds to healthcare providers, and the proposed management of the net settlement funds by the applicant's husband in China.

The applicant requested a reconsideration of a Licence Appeal Tribunal decision that denied his entitlement to an income replacement benefit (IRB), interest, and an award.

The applicant argued that the Tribunal breached procedural fairness and made errors of law in assessing the validity of the insurer's notices under section 36(4) of the Statutory Accident Benefits Schedule.

The Vice-Chair dismissed the reconsideration request, finding no breach of procedural fairness and concluding that the rehearing adjudicator correctly applied the law in determining that the insurer's requests for information were compliant, thereby not triggering the mandatory payment provisions of section 36(6).

The applicant sought statutory accident benefits following a motor vehicle accident, arguing he should be removed from the Minor Injury Guideline (MIG) due to chronic pain and a psychological condition.

The Licence Appeal Tribunal found insufficient evidence of accident-related chronic pain with functional impairment, noting the applicant's medical records primarily documented non-accident-related concerns.

The Tribunal also placed little weight on a psychological pre-screen report that relied on self-reporting without validity measures.

The application was dismissed, and the applicant was held to the $3,500 MIG limit, rendering the disputed treatment plans moot.

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 applicant argued that she suffered from chronic pain and psychological impairments warranting removal from the MIG, and sought a non-earner benefit (NEB) and various treatment plans.

The Tribunal found that the applicant failed to prove on a balance of probabilities that her injuries fell outside the MIG, noting a lack of compelling medical evidence linking her chronic pain and psychological complaints to the accident.

The Tribunal also dismissed the claim for an NEB, finding insufficient evidence comparing her pre- and post-accident activities.

The application was dismissed.