Statutory Accident Benefits Schedule matters (SABS)

Zurich appealed a Superior Court decision that held Zurich and Chubb equally responsible for paying statutory accident benefits to a claimant injured in a rental vehicle.

The claimant initially applied to Chubb, who denied the claim and failed to notify Zurich within 90 days as required by O. Reg. 283/95.

The second arbitrator found Chubb solely responsible for the benefits due to its breaches of sections 2 and 3 of the Regulation.

The appeal judge overturned this, finding the insurers should share responsibility.

The Court of Appeal allowed Zurich's appeal and reinstated the arbitrator's award, holding that the appeal judge erred in treating the insurers as having equal priority under section 268 of the Insurance Act.

The arbitrator reasonably exercised his discretion in requiring Chubb to pay the benefits permanently as a consequence of its breaches.

The applicant sought statutory accident benefits following a motor vehicle accident, including attendant care benefits, medication expenses, visitor expenses, and damaged clothing expenses.

The Tribunal found that the applicant had exhausted the $65,000 monetary limit for medical, rehabilitation, and attendant care benefits.

Furthermore, the applicant failed to prove that her non-professional attendant care provider suffered an economic loss or that the claimed services were actually provided.

The claims for medication, visitor expenses, and damaged clothing were also dismissed due to a lack of supporting evidence establishing causation, reasonableness, or ownership.

The application was dismissed in its entirety.

The applicant, a pedestrian making a delivery for Uber Eats, was struck by an e-scooter and sought statutory accident benefits.

The respondent denied the claim on the basis that an e-scooter is not an 'automobile' and therefore the incident was not an 'accident' under s. 3(1) of the Schedule.

The Tribunal applied the Adams test and found that the applicant failed to provide sufficient evidence regarding the e-scooter's features to prove it was an automobile in ordinary parlance.

The application was dismissed.

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

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

The applicant argued that chronic pain and psychological impairments warranted removal from the MIG.

The Tribunal found that the applicant failed to demonstrate a psychological impairment or chronic pain with functional impairment, placing significant weight on the respondent's psychological assessment which found only subclinical symptoms.

As the applicant remained within the MIG, the disputed treatment plans were not payable.

Claims for an award for unreasonable delay and interest were also dismissed.

The applicant requested a reconsideration of a Licence Appeal Tribunal decision that denied a treatment plan for home modifications.

The applicant argued the Tribunal breached procedural fairness and made errors of law and fact by misapprehending evidence related to causation and the characterization of his impairments.

The Adjudicator dismissed the request, finding that the original decision applied the correct legal test for causation and provided thorough reasons for the weight assigned to the evidence.

The Adjudicator concluded the applicant was attempting to re-litigate the weight of the evidence rather than demonstrating a reviewable error.

The applicant sought entitlement to a $2,044.17 treatment plan for medical marijuana following a motor vehicle accident, along with interest and an award for unreasonable delay.

The Licence Appeal Tribunal found that the medical evidence, including clinical notes and records from treating physicians and psychological assessments, did not recommend or support the use of medical marijuana for the applicant's chronic pain or psychological impairments.

The application was dismissed, and claims for interest and a section 10 award were consequently denied.

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

The respondent raised a preliminary issue, arguing the applicant was statute-barred from proceeding to a hearing for failing to attend a scheduled insurer's examination.

The Tribunal found that the applicant had provided a reasonable explanation for her non-attendance, having notified the respondent of a scheduling conflict prior to the examination and requested a rescheduled date, to which the respondent did not reply.

The applicant was permitted to proceed to a substantive hearing.

The applicant's request for costs was denied due to a lack of supporting submissions or evidence.

The applicant sought statutory accident benefits following a motor vehicle accident, specifically claiming entitlement to an in-home assessment and five chiropractic treatment plans.

The respondent had removed the applicant from the Minor Injury Guideline (MIG) prior to the hearing.

The Tribunal found that the applicant failed to prove on a balance of probabilities that the disputed treatment plans were reasonable and necessary, noting that the medical evidence did not adequately explain why five duplicative chiropractic plans were required.

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

The applicant sought statutory accident benefits following a motor vehicle accident, claiming her injuries, including a concussion and pre-existing spinal conditions, warranted removal from the Minor Injury Guideline (MIG).

The Tribunal found the applicant failed to provide compelling medical evidence from a qualified physician to support a concussion diagnosis or demonstrate that a pre-existing condition precluded recovery under the MIG.

The Tribunal also denied a $755.00 claim for physiotherapy services, finding the insurer's denial notice complied with the Schedule.

The application was dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident, disputing the respondent's denial of multiple treatment and assessment plans, medication expenses, and parking costs.

The Tribunal found that the applicant failed to prove on a balance of probabilities that the proposed in-home, attendant care, neurological, concussion, chiropractic, physiotherapy, and psychological plans were reasonable and necessary, preferring the objective findings of the respondent's assessors over the subjective reporting relied upon by the applicant's assessors.

The Tribunal awarded the cost of one prescription medication and interest on overdue payments, but denied the remaining expenses and the claim for a special award under s. 10 of Reg. 664.

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

The Tribunal found that the applicant's injuries, including mild carpal tunnel syndrome and psychological symptoms, were predominantly minor and subject to the Minor Injury Guideline (MIG) limit.

As the MIG limit was exhausted and the insurer's denial notices were compliant with s. 38(8) of the Schedule, the disputed treatment and assessment plans were denied.

The Tribunal awarded pre-104 week income replacement benefits (IRBs) in varying amounts, accounting for the applicant's post-accident employment income, but denied post-104 week IRBs as the applicant failed to prove a complete inability to engage in suitable employment.

A claim for a special award under s. 10 of Regulation 664 was also dismissed.

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

The respondent denied the claim on the basis that the applicant was entitled to income replacement benefits instead.

The applicant disputed the denial more than four years after the two-year limitation period expired.

The Tribunal found the respondent's denial was clear, unequivocal, and valid, triggering the limitation period.

The Tribunal declined to extend the limitation period under section 7 of the Licence Appeal Tribunal Act, finding no bona fide intention to appeal, substantial delay, and prejudice to the respondent.

The application was dismissed as statute-barred.

The applicant requested a reconsideration of a Licence Appeal Tribunal decision which found she was not catastrophically impaired and denied a treatment plan for a catastrophic assessment.

The applicant argued the adjudicator erred in weighing the medical evidence, particularly regarding a pre-existing 2019 accident, and placed undue weight on surveillance evidence showing her speeding.

The Vice-Chair dismissed the request, finding the applicant was improperly attempting to re-weigh the evidence rather than identifying an error of law or fact.

The Tribunal also upheld the denial of the treatment plan balance, noting the applicant failed to explain why an amount greater than the statutory cap was reasonably required.

The applicant sought a determination of catastrophic impairment and entitlement to various medical, rehabilitation, and transportation benefits following a motor vehicle accident.

The Licence Appeal Tribunal found that the applicant did not sustain a catastrophic impairment under either Criterion 7 (55% Whole Person Impairment) or Criterion 8 (mental or behavioural disorder), preferring the respondent's medical evidence which indicated lower impairment ratings.

However, the Tribunal granted the applicant's claims for a psychological treatment plan and an occupational therapy assessment, finding them reasonable and necessary.

The claims for transportation expenses were dismissed for lack of evidence.

The applicant sought entitlement to a physiotherapy treatment plan following a motor vehicle accident.

The respondent argued the applicant was statute-barred from proceeding to a hearing for failing to attend a scheduled insurer examination.

The Tribunal found the respondent's notices of examination were non-compliant with section 44(5)(a) of the Schedule, as they lacked specific medical reasons, meaning the applicant was not barred from proceeding.

However, on the substantive issue, the Tribunal dismissed the claim for the treatment plan, finding the applicant's reported injuries and limitations were inconsistent and uncorroborated by the clinical notes and records of his family physician.

The applicant requested a reconsideration of a Licence Appeal Tribunal decision that partially denied a treatment plan for home modifications, including the location of a new garage, new flooring, electrical rewiring, and a therapy room addition.

The applicant argued the adjudicator made errors of law and fact, specifically regarding the Tribunal's jurisdiction to consider municipal encroachment for the garage location and the assessment of tripping hazards.

The Tribunal dismissed the request, finding no errors of law or fact.

The adjudicator confirmed the Tribunal lacks jurisdiction under section 280 of the Insurance Act to determine municipal encroachment issues and held that the applicant was attempting to re-litigate findings of fact and raise new arguments not presented at the initial hearing.

The applicant sought a determination that she sustained a catastrophic impairment as a result of a 2021 motor vehicle accident, relying on Criterion 8 (mental and behavioural impairments).

The respondent denied the claim, arguing the impairments were moderate and partially pre-existing.

The Tribunal preferred the evidence of the applicant's experts, finding that the applicant suffered marked impairments in all four spheres of function (activities of daily living, social functioning, concentration/persistence/pace, and adaptation).

The Tribunal concluded the applicant sustained a catastrophic impairment as a direct result of the accident.

The applicant and respondent both requested reconsideration of a Tribunal decision that dismissed the application for failure to file submissions.

The parties had previously informed the Tribunal that a settlement had been reached and was awaiting court approval because the applicant is a minor.

The Tribunal found that there was a misunderstanding of fact based on the parties' correspondence, satisfying the grounds for reconsideration under Rule 18.2(b).

The original decision was cancelled and the file was closed without prejudice pending court approval of the settlement.

The applicant sought various statutory accident benefits following a motor vehicle accident, including an income replacement benefit (IRB), medical benefits, and an award under s. 10 of O. Reg 664.

The Tribunal found the applicant did not suffer a substantial inability to perform the essential tasks of his employment as a personal support worker and Lyft driver, relying on the respondent's medical assessments and the applicant's family doctor's clinical notes.

The Tribunal denied the claims for IRB, psychological services, a chronic pain assessment, and a driving reintegration assessment.

However, the Tribunal partially approved a treatment plan for a chronic pain program, awarding $2,346.70 for physical therapy and an SI belt based on a neutral OHIP-funded assessment.

The claim for a s. 10 award was dismissed.

This appeal concerns the interpretation of Ontario's Statutory Accident Benefits Schedules regarding attendant care benefits (ACBs) for a catastrophically injured individual.

The key issues were whether an applicant for ACBs must demonstrate "urgency, impossibility, or impracticability" to claim retroactive benefits under s. 42(5) of the 2010 Schedule, and whether the definition of "incurred" from s. 3(7)(e) of the 2010 Schedule applies to claims arising from accidents predating its enactment (specifically, the 1996 Schedule).

The Court of Appeal found that s. 42(5) relates to the timing of payment, not eligibility, and does not impose a "urgency" test for retroactive claims.

It further held that the definition of "incurred" in the 2010 Schedule does not apply to claims governed by the 1996 Schedule, based on a careful reading of the transitional provisions.

The appeal was allowed, entitling the applicant to retroactive ACBs without substantiation under the 2010 Schedule's "incurred" definition.