Statutory Accident Benefits Schedule matters (SABS)

The applicant sought a determination that she sustained a catastrophic impairment under Criterion 8 of the Statutory Accident Benefits Schedule following a motor vehicle accident.

The applicant claimed marked impairments in social functioning, concentration, persistence and pace, and adaptation due to psychological issues including depression and anxiety.

The Tribunal preferred the evidence of the respondent's assessors, finding that the applicant's impairments were moderate (Class 3) rather than marked (Class 4).

The Tribunal noted the applicant's ability to maintain relationships, travel, manage her children's schedules, and handle personal affairs, concluding she did not meet the threshold for catastrophic impairment.

The application was dismissed.

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

The respondent insurer denied benefits, arguing the applicant failed to notify it of the accident within seven days as required by s. 32(1) of the Schedule, and failed to submit the application within 30 days under s. 32(5).

The Tribunal found that the applicant had informed the insurer of the accident and property damage within seven days, which, following binding Divisional Court authority, was sufficient notice of an intention to seek benefits.

The insurer failed to prove it provided the required application forms, so the 30-day limit under s. 32(5) was not triggered.

The applicant was permitted to proceed to a substantive hearing.

The applicant requested a reconsideration of a preliminary issue decision which dismissed his application for lack of jurisdiction because he had not returned $90,000 in settlement funds as required by s. 9.1(8) of Regulation 664.

The applicant argued the adjudicator erred in law by not first determining if the settlement was valid and breached procedural fairness by not ruling on a motion to strike reply submissions.

The Tribunal dismissed the reconsideration request, finding no error of law or breach of procedural fairness, as the return of settlement funds is a mandatory precondition to disputing a settlement's validity.

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

The respondent insurer raised a preliminary issue that the applicant was statute-barred from proceeding because he submitted his application for benefits (OCF-1) beyond the 30-day prescribed time limit.

The Tribunal found that the respondent failed to prove it properly delivered the application package or explained the process to the applicant, who had limited English skills and had not consented to email delivery.

Applying the Horvath factors, the Tribunal concluded the applicant had a reasonable explanation for the delay and allowed the claim to proceed.

The applicant sought post-104 income replacement benefits and a physiotherapy treatment plan following a low-speed motor vehicle accident.

The Tribunal found that the applicant's physical, psychological, and pain complaints did not render her completely unable to engage in employment for which she is reasonably suited, such as customer service or hairstyling.

The Tribunal preferred the evidence of the respondent's assessors and contemporaneous medical records over the applicant's experts.

The treatment plan was denied as past similar treatments had not been effective.

The application was dismissed.

The applicant requested a reconsideration of a Licence Appeal Tribunal decision that denied her claims for an attendant care benefit and other medical benefits.

She argued the Tribunal committed a material breach of procedural fairness and errors of law and fact by ignoring evidence, refusing an electronic hearing, and dismissing the attendant care claim in its entirety despite a partial concession by the respondent.

The Tribunal dismissed the reconsideration request, finding that the allegedly ignored evidence had not been properly filed, the written hearing format was appropriate, and the entire quantum of the attendant care benefit was properly in dispute.

The applicant sought statutory accident benefits following a motor vehicle accident, including a $1,954.30 physiotherapy treatment plan.

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

The applicant argued for removal from the MIG based on a psychological impairment and post-concussion syndrome.

The Tribunal found that the applicant failed to provide sufficient medical evidence to establish an accident-related psychological impairment or concussion.

The adjudicator accepted the respondent's section 44 assessment and hospital records indicating minor physical injuries.

The application was dismissed, and the applicant remains subject to the MIG.

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

The respondent insurer split the determination of her injuries, subjecting her physical injuries to the Minor Injury Guideline (MIG) limits while accepting her psychological injuries were non-minor.

The applicant applied to the Licence Appeal Tribunal.

At the case conference, the respondent agreed to pay the disputed benefits.

The Tribunal held a written hearing to determine if the applicant was entitled to an award under section 10 of Regulation 664.

The Tribunal found the respondent's position to split the determination was contrary to settled law and constituted unreasonable withholding of benefits.

The applicant was awarded $3,194.41, representing 50% of the amounts withheld based on the split determination.

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

The matter proceeded to a written hearing.

The applicant failed to file any submissions or evidence by the deadline and did not respond to the Tribunal's follow-up communications.

As the applicant bore the onus of proving entitlement to the disputed benefits, the Tribunal found the applicant failed to meet this burden.

The application was dismissed.

The respondent insurer requested a reconsideration of a Tribunal decision which found that the applicant had a reasonable explanation for the late submission of his Application for Accident Benefits (OCF-1).

The insurer argued that the adjudicators erred in their assessment of the applicant's credibility and the reasonableness of his explanation, specifically regarding when he retained counsel and his post-accident medical complications.

The Tribunal dismissed the request for reconsideration, finding that the insurer was attempting to re-litigate findings of fact and had failed to establish any error of law or fact that would warrant varying the decision.

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

The respondent raised a preliminary issue, arguing the applicant was barred from proceeding to a hearing because she failed to attend scheduled insurer's examinations.

The Tribunal found the respondent's notices for two treatment plans complied with the Schedule, barring the applicant from proceeding with those claims.

However, the notices for a third treatment plan and non-earner benefits were non-compliant, allowing the applicant to proceed to a substantive hearing on those issues.

The applicant sought non-earner benefits following a motor vehicle accident, which the respondent insurer denied.

The applicant applied to the Licence Appeal Tribunal more than two years after the denial.

The Tribunal found that the respondent's denial letters were clear and unequivocal, satisfying the requirements to trigger the two-year limitation period under section 56 of the Schedule.

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

The application was dismissed as statute-barred.

The applicant sought a non-earner benefit (NEB) and funding for physiotherapy and psychological services following a motor vehicle accident.

The Licence Appeal Tribunal dismissed the application, finding the applicant failed to prove a complete inability to carry on a normal life due to significant inconsistencies in his self-reports regarding employment and daily activities.

The Tribunal preferred the respondent's physiatry assessment over the applicant's evidence, concluding the proposed treatment plans were not reasonable and necessary.

Claims for interest and an award were also dismissed.

The applicant sought statutory accident benefits for chiropractic services, psychological services, and assistive devices following a motor vehicle accident.

The respondent insurer denied the treatment plans, arguing the applicant's symptoms were due to pre-existing conditions and that the treatments were not reasonable and necessary.

The Tribunal found the chiropractic treatment plans and assistive devices were reasonable and necessary based on the treating family physician's clinical notes, though it reduced the amounts awarded for the assistive devices to their retail cost and capped the second chiropractic plan.

The claim for psychological services was dismissed for lack of supporting evidence.

The applicant sought a determination of catastrophic impairment following a motor vehicle accident, claiming a class 5 extreme mental and behavioural impairment.

The applicant moved to exclude the respondent's insurer's examination report by a psychologist, which the Tribunal denied, finding that the restrictions in section 45(2) of the Schedule apply to insured persons, not insurers.

On the merits, the Tribunal found the applicant did not sustain a catastrophic impairment, giving no weight to her psychiatric expert's report due to methodological deficiencies, lack of an occupational therapy assessment, and over-reliance on the applicant's inconsistent self-reporting.

The application for benefits and an award was dismissed.

The applicant sought entitlement to an income replacement benefit (IRB) and a physiotherapy treatment plan following a motor vehicle accident.

The respondent had terminated the IRB based on multidisciplinary assessments concluding the applicant did not suffer a substantial inability to perform the essential tasks of her pre-accident employment as a restaurant server.

The Tribunal found the applicant failed to provide supporting medical documentation to meet her onus for both the IRB and the treatment plan, relying instead on perceived deficiencies in the respondent's evidence.

The Tribunal accepted the respondent's medical evidence that the applicant's injuries were transient soft tissue injuries and that her psychological issues did not prevent her from working.

The application was dismissed in its entirety, including claims for interest and an award.

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

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

The applicant argued for removal from the MIG based on psychological impairments and chronic pain.

The Tribunal found that the applicant's psychological and chronic pain evidence was outweighed by the respondent's expert assessments and the lack of contemporaneous complaints in the family doctor's clinical notes.

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

Consequently, the disputed treatment plans, interest, and an award for unreasonable delay were denied.

The applicant requested a reconsideration of a previous Tribunal decision that barred her from proceeding to a hearing on several treatment plans due to her failure to attend an insurer's examination.

The applicant argued that the Tribunal made errors of law and fact, and that new evidence—specifically her subsequent removal from the Minor Injury Guideline—should alter the outcome.

The Tribunal dismissed the reconsideration request, finding no errors of law or fact in its previous determinations regarding the validity of the notices of examination and denial letters at the time they were issued.

The Tribunal also found that the new evidence did not meet the criteria for reconsideration.

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

In a prior decision, the Tribunal determined that the applicant's injuries fell within the Minor Injury Guideline (MIG).

The applicant filed a new application seeking payment for additional treatment plans, arguing he should be removed from the MIG.

The respondent raised a preliminary issue that the application was barred by res judicata.

The Tribunal found that the issue of the MIG had already been decided in a final decision between the same parties.

The Tribunal rejected the applicant's argument that new treatment plans constituted fresh evidence warranting a waiver of res judicata.

The application was dismissed.

The applicant sought income replacement benefits (IRBs) beyond the 104-week post-accident mark, requiring him to prove a complete inability to engage in any reasonably suited employment.

The respondent insurer denied the benefits, relying on surveillance evidence and expert reports suggesting the applicant had some capacity for work.

The Tribunal found the applicant's testimony, corroborated by his spouse and medical evidence, established that his chronic pain and severe psychological impairments prevented him from sustaining employment.

The Tribunal placed significant weight on the applicant's experts and found the surveillance evidence did not contradict his reported limitations.

The applicant was awarded ongoing IRBs and interest on overdue payments.