Statutory Accident Benefits Schedule matters (SABS)

The applicant sought statutory accident benefits following a motor vehicle accident, including treatment plans for physiotherapy, chiropractic services, a manual wheelchair, and a catastrophic assessment.

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

The medical evidence, including clinical notes and records from the applicant's family doctor and an orthopaedic examination, indicated that the applicant suffered whiplash and lumbar strain and had likely reached maximum medical recovery.

Claims for a section 10 award and interest were also dismissed.

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

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

The applicant applied to the Licence Appeal Tribunal, arguing that physical injuries, psychological impairments, and chronic pain warranted removal from the MIG.

The Tribunal found that the applicant's physical injuries were sprains and strains, the psychological claims lacked a formal diagnosis, and the chronic pain claims were unsupported by evidence of functional impairment.

As the $3,500 MIG limit had been exhausted, the application for the disputed treatment plans and interest was dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident, claiming entitlement to non-earner benefits and various treatment plans outside the Minor Injury Guideline (MIG).

The adjudicator found that the applicant failed to prove her psychological impairments, physical injuries, or chronic pain warranted removal from the MIG.

Furthermore, the applicant did not provide sufficient evidence comparing her pre- and post-accident activities to establish a complete inability to carry on a normal life.

The application was dismissed, and the applicant was found not entitled to the disputed benefits or interest.

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 prove a chronic pain diagnosis or a pre-existing condition that would warrant removal from the MIG.

The Tribunal also dismissed the claim for a non-earner benefit, finding the applicant did not suffer a complete inability to carry on a normal life, as evidenced by surveillance and medical reports.

The application was dismissed in its entirety.

The applicant sought statutory accident benefits following a motor vehicle accident, including attendant care benefits and several treatment plans for occupational therapy, physiotherapy, and a chronic pain assessment.

The adjudicator dismissed the application in its entirety.

The adjudicator preferred the respondent's section 44 assessments over the applicant's evidence, finding the applicant's occupational therapy report to be of limited evidentiary value due to inconsistencies with clinical notes and records.

Furthermore, the applicant failed to meet her evidentiary burden for the treatment plans by not providing copies of the disputed OCF-18s or specific submissions addressing the goals and costs of the proposed treatments.

The applicant requested a reconsideration of a previous Tribunal decision denying various assessments and a special award.

The applicant argued the Tribunal erred in denying the balance of a catastrophic assessment and that new evidence supported a special award.

The Tribunal found it had erred regarding the catastrophic assessment balance, but noted the respondent had already paid the outstanding HST amount.

The Tribunal also found the alleged new evidence regarding the special award was already before it and would not have changed the outcome.

The request for reconsideration was dismissed.

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

The respondent brought a preliminary motion to bar the applicant from proceeding on several issues due to his failure to attend a scheduled insurer's examination.

The Tribunal found the applicant was barred from proceeding on the Minor Injury Guideline, a doctor's appointment expense, and a psychological assessment because he failed to attend the examination without a reasonable explanation.

On the substantive issue of the non-earner benefit, the Tribunal found the applicant was not entitled to the benefit as he had substantially returned to his pre-accident activities, including successfully returning to college classes.

The application was dismissed.

The applicant sought various statutory accident benefits, including attendant care, physiotherapy, and occupational therapy, following a 2018 motor vehicle accident.

The adjudicator dismissed the application in its entirety, finding the applicant was a poor historian and failed to meet his onus to prove the expenses were reasonable and necessary or incurred.

The adjudicator preferred the respondent's medical evidence, noting the applicant's significant pre-existing health issues, including severe osteoarthritis that necessitated a knee replacement.

The respondent's request for costs was also denied.

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

The insurer denied the claim, arguing the applicant failed to report the accident within the prescribed 7-day timeline.

The Tribunal found the applicant was not barred from proceeding, as the insurer failed to produce complete log notes and had misled the applicant about settling the claim.

On the substantive issues, the Tribunal found the applicant's injuries fell within the Minor Injury Guideline (MIG) and denied the claim for a non-earner benefit.

The Tribunal ordered the insurer to pay a $2,200 treatment plan because the applicant was entitled to treatment within the MIG limit, but denied a $1,302.49 treatment plan that proposed treatment outside the MIG.

The applicant sought statutory accident benefits for physiotherapy services and a catastrophic impairment assessment following a motor vehicle accident.

The insurer denied the benefits, arguing the applicant had reached maximum medical recovery and had not shown a change in condition to warrant a second catastrophic assessment.

The Tribunal agreed with the insurer, finding that the applicant's large gaps in treatment and the medical evidence indicated maximum medical recovery.

The Tribunal also found no evidence of a worsened condition to justify an additional catastrophic impairment assessment.

The application was dismissed.

The applicant sought accident benefits following a motor vehicle accident.

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

The Tribunal found the applicant did not establish chronic pain or a pre-existing condition to warrant removal from the MIG.

The claim for a non-earner benefit was dismissed as the applicant failed to demonstrate a complete inability to carry on a normal life.

However, the Tribunal ordered the insurer to pay a $4,114.05 physiotherapy treatment plan because the insurer failed to provide a compliant denial notice within the required 10 business days under s. 38(8) of the Schedule.

A second treatment plan was denied as the insurer's notice was compliant.

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

The Tribunal found that the applicant's chronic pain and functional restrictions warranted removal from the Minor Injury Guideline.

The applicant was awarded income replacement benefits for the period she was unable to perform the essential tasks of her employment as a pharmacy assistant.

The Tribunal also approved several treatment plans for physiotherapy and assessments, noting the insurer's failure to provide compliant medical reasons for denying the assessments.

Claims for attendant care benefits and a special award were dismissed.

The applicant sought entitlement to statutory accident benefits for physiotherapy and psychological services following a motor vehicle accident.

The Licence Appeal Tribunal found that the applicant failed to demonstrate that the proposed treatment plans were reasonable and necessary.

The medical evidence did not support the need for further facility-based treatment, and the applicant failed to provide sufficient explanation for the increased length and cost of psychological sessions.

The application was dismissed.

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

The applicant's mother held a policy with the respondent.

The Tribunal found that the deceased father was not an "insured person" under the mother's policy, as they were not spouses and he was not a dependent.

The application for a death benefit was dismissed.

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

The respondent insurer denied the claims, and the applicant applied to the Tribunal more than two years after the denials.

The preliminary issue was whether the claims were statute-barred under s. 56 of the Schedule.

The Tribunal found that the denial notice for non-earner benefits was defective as it lacked specific medical reasons, meaning the limitation period was not triggered for that claim.

However, the denial notices for the treatment and assessment plans were valid and triggered the limitation period.

As the applicant did not file within two years and provided no grounds for an extension under s. 7 of the Licence Appeal Tribunal Act, the claims for the treatment and assessment plans were statute-barred.

The applicant sought statutory accident benefits following a 2019 motor vehicle accident, specifically a $19,097.00 treatment plan for a catastrophic impairment (CAT) assessment and an award for unreasonable delay.

The Tribunal found the applicant was entitled to $9,266.00 for the CAT assessment, approving the physiatry, psychiatry, and occupational therapy components, but denying duplicative or premature elements like the intake assessment and OCF-19 completion.

The Tribunal admitted several late or disputed medical reports, finding them relevant and not prejudicial.

The claim for a special award was dismissed as the insurer's denial was not unreasonable, though interest was awarded on the overdue assessment costs.

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 the $3,500 limit had been exhausted.

The applicant argued she suffered from chronic pain and psychological injuries that removed her from the MIG.

The Tribunal found the applicant did not meet the criteria for chronic pain, noting her own self-evaluations indicated 100% improvement shortly after the accident.

The Tribunal also preferred the respondent's psychological assessment, which found no psychological impairment warranting a DSM-5 diagnosis.

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

As the MIG limit was exhausted, the disputed treatment and assessment plans were not payable.

The insurer applied to the Licence Appeal Tribunal for repayment of $15,764.81 in medical and rehabilitation benefits paid to the respondent, alleging the subject accident was staged.

In a previous preliminary issue decision, the Tribunal found the accident was staged and excluded from the definition of an accident under the Schedule.

Relying on this finding, the Tribunal concluded the respondent wilfully misrepresented the facts of the accident to receive benefits.

The Tribunal ordered the respondent to repay the benefits in full, plus applicable interest.

The plaintiffs commenced an action against their automobile insurer alleging breach of contract, entitlement to various statutory accident benefits, and damages for bad faith following a 1999 motor vehicle accident.

They sought payment for a proposed medical assessment, vocational training and educational expenses, the cost of a spinal cord stimulator, and damages arising from alleged improper claims handling.

The court found that the plaintiffs failed to establish entitlement to the claimed benefits because the assessments and treatments were not proven to be reasonably required and several claims were not properly submitted or mediated under the applicable Statutory Accident Benefits Schedule.

The court also held that the insurer’s conduct did not constitute bad faith and did not represent a marked departure from ordinary standards of decency.

The action was dismissed in its entirety.

Two related actions arising from a motor vehicle accident involved disputes over defence medical examinations.

In the tort action, the defendant’s insurer sought a psychiatric defence medical examination, while in the separate action against the plaintiff’s own insurer the plaintiff sought an order that the same examination would serve both defendants.

The court held that the insurers were adverse in interest because each could attribute the plaintiff’s ongoing psychological condition to the other’s conduct, particularly in light of allegations that the insurer’s handling of accident benefits exacerbated the plaintiff’s injuries.

The court further held that adversity between co‑defendants is not a necessary precondition to separate defence medical examinations; the governing consideration is fairness in the adversarial process.

The third party insurer was permitted to conduct the psychiatric examination and the plaintiff’s motion to bind the other insurer to that examination was dismissed.