Statutory Accident Benefits Schedule matters (SABS)

The applicant sought a catastrophic impairment determination and submitted medical reports.

The respondent's assessors concluded she did not meet the criteria.

The applicant then submitted addendum reports.

The respondent brought a motion to allow its assessors to prepare responding addendum reports without the applicant's consent, arguing the applicant's addenda contained new opinions and comments.

The Tribunal dismissed the motion, finding that the applicant's addendum reports merely reaffirmed their original positions and did not raise new issues that would justify further examinations under section 44 of the Schedule.

The applicant sought statutory accident benefits following a motor vehicle accident, including attendant care benefits, medical benefits for physiotherapy and chiropractic services, and the costs of various assessments.

The Licence Appeal Tribunal dismissed the application in its entirety.

Relying on insurer's examinations and the applicant's own self-reporting, the adjudicator found that the applicant was independent in her self-care, had returned to work, and had reached maximum medical recovery, rendering the disputed treatment and assessments not reasonable and necessary.

The applicant sought statutory accident benefits following an alleged incident on a public transit bus.

The insurer denied the claim on the basis that no collision occurred, as required by section 268(1.1) of the Insurance Act.

The Tribunal found that the applicant's testimony of feeling a bump while half asleep was insufficient to prove a collision occurred, especially given the lack of an incident report from the transit service and a three-month delay in reporting.

The application was dismissed.

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

The respondent requested further independent examinations (IEs) under s. 44 of the Statutory Accident Benefits Schedule to address attendant care and home modifications.

The applicant refused to attend, citing mental and physical health issues, and argued the respondent should rely on paper reviews of his experts' reports.

The Tribunal held that procedural fairness requires the respondent to have the opportunity to challenge the applicant's medical evidence with its own assessors.

The Tribunal suspended the applicant's right to proceed with all issues, except housekeeping expenses, until he attends the requested IEs.

The respondent insurer filed a request for reconsideration of a preliminary decision that allowed the applicant insured to proceed with her application for income replacement benefits despite failing to attend seven scheduled insurer examinations.

The insurer argued the applicant should be completely barred from proceeding due to prejudice.

The Tribunal dismissed the request for reconsideration, finding no error of law or fact in the preliminary decision.

The Tribunal upheld the original order requiring the applicant to attend rescheduled insurer examinations as a condition of proceeding with her application, noting the applicant had provided reasonable explanations for missing some of the appointments.

The applicant brought a motion seeking to exclude potential surveillance evidence, obtain funding for a section 25 vocational report, and rely on written expert reports without producing the experts for cross-examination.

The Licence Appeal Tribunal dismissed the motion.

The request regarding surveillance was moot as the insurer confirmed no such evidence existed.

The request for a section 25 report was denied because the applicant failed to establish that her condition had changed since her previous assessment.

Finally, the Tribunal held that if the applicant intends to rely on expert reports, she must make those experts available for cross-examination by the respondent.

The applicant sought payment for two physiotherapy treatment plans following a motor vehicle accident.

The respondent denied the plans on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG) and were subject to the $3,500 cap.

The applicant argued she suffered chronic pain and psychological damage taking her outside the MIG.

The Tribunal found the applicant failed to prove on a balance of probabilities that her injuries were more than predominantly minor, preferring the objective clinical notes of her family physician over her chiropractor's records.

The application for benefits was dismissed.

The applicant was injured in a motor vehicle accident and sought medical and rehabilitation benefits for physiotherapy.

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

The applicant argued that his injuries, including bicipital tendinitis, chronic pain, and psychological impairments, as well as a pre-existing developmental disability, removed him from the MIG.

The Tribunal found that the applicant failed to provide compelling evidence to establish that his injuries fell outside the MIG or that his pre-existing condition prevented maximal recovery within the MIG limits.

As the $3,500 MIG limit had already been exhausted, the application for further benefits and interest was dismissed.

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

The respondent insurer denied the claims, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) and were subject to the $3,500 limit.

The Licence Appeal Tribunal found that the applicant failed to prove her injuries were more than soft tissue in nature or that she had a pre-existing condition warranting removal from the MIG.

The Tribunal preferred the respondent's psychological assessment, which found no psychological impairment, over the applicant's evidence.

The application for benefits was dismissed.

The applicant sought statutory accident benefits for dental services following a motor vehicle accident.

The insurer denied the claim, arguing the dental issues were not caused by the accident.

The Tribunal found that the applicant failed to prove causation, noting the absence of reported dental injuries in the immediate post-accident medical records and a documented history of pre-existing dental problems.

Relying on the insurer's dental examination report, the Tribunal concluded the recommended treatments likely addressed pre-existing deficiencies.

The application for benefits, interest, and a special award was dismissed.

The applicant, a taxi driver, was assaulted by a passenger after leaving his vehicle and following the passenger into a laneway to collect an unpaid fare.

He applied for statutory accident benefits, which the respondent insurer denied on the basis that the incident was not an 'accident' under the Schedule.

The Licence Appeal Tribunal applied the two-part purpose and causation test from Greenhalgh.

The Tribunal found that leaving the taxi to collect a fare was not an ordinary use or operation of the vehicle, and that the assault was a distinct and severable intervening act that broke the chain of causation.

The application was dismissed.

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

The respondent insurer denied ongoing non-earner benefits and asserted the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found that the applicant's pre-existing medical conditions, including a severe lung condition, prevented her from achieving maximal recovery within the MIG, thus excluding her from its limits.

The Tribunal also held that the respondent was required to pay non-earner benefits for a closed period because it failed to provide proper notice of an insurer's examination.

However, ongoing non-earner benefits were denied because the applicant's current complete inability to carry on a normal life was caused by her pre-existing lung condition and osteoarthritis, not the accident.

The applicant sought various medical assessments following a 2010 motor vehicle accident.

The respondent insurer denied the assessments.

The Licence Appeal Tribunal found that the chronic pain and physiatry assessments were reasonably required due to consistent medical evidence of ongoing ankle pain and the risk of progressive osteoarthritis.

However, the Tribunal dismissed the claims for work site, psychological, attendant care, and function and impairment assessments, finding insufficient evidence to support their necessity, particularly given the applicant's independence in self-care and lack of documented psychological symptoms prior to 2014.

Interest was awarded on the overdue payments for the approved assessments.

The applicant sought income replacement benefits following a motor vehicle accident, claiming he was unable to perform his pre-accident work as a self-employed mason.

The adjudicator dismissed the application, finding insufficient contemporaneous medical evidence to prove a substantial inability to perform the essential tasks of his employment.

The adjudicator noted that functional testing was deemed invalid due to the applicant's sub-maximal effort, and no financial documentation was provided to demonstrate an actual loss of income during the disputed period.

The applicant was injured in a motor vehicle accident and sought payment for chiropractic and massage therapy treatment plans under the Statutory Accident Benefits Schedule.

The respondent insurer denied the plans based on insurer's examinations.

The Tribunal found the applicant credible and held that the treatment plans were reasonable and necessary as they provided temporary pain relief that allowed the applicant to maintain workplace attendance and perform daily activities.

The Tribunal placed less weight on the insurer's examinations, finding them unhelpful or taken out of context.

The applicant was awarded the cost of the treatment plans and interest on overdue payments.

The applicant insurer sought repayment of $4,776.44 in statutory accident benefits paid to the respondent for prescription medication expenses.

The respondent had received payments from the Trillium drug benefit program for the same expenses but submitted claims to the applicant, effectively misrepresenting that she was out-of-pocket.

The respondent did not participate in the hearing.

The Tribunal found that the overpayments were the result of wilful misrepresentation, meaning no limitation period applied to the repayment request.

The respondent was ordered to repay the full amount plus interest.

The applicant was injured in a motor vehicle accident and subsequently sustained a disc herniation while performing deadlifts with a personal trainer to strengthen his back.

The respondent denied income replacement benefits, arguing the disc herniation was a separate injury not caused by the accident.

The Tribunal applied the 'but for' test and found the disc herniation was causally connected to the accident, as the applicant was performing the exercises to rehabilitate his accident-related back injury.

The Tribunal concluded the applicant suffered a substantial inability to perform the essential tasks of his employment for the first 104 weeks, and a complete inability to engage in suitable employment thereafter.

The applicant was awarded ongoing income replacement benefits and the cost of a vocational assessment.

The applicant sought medical benefits for treatments following a motor vehicle accident.

The Licence Appeal Tribunal dismissed the application, finding that the applicant failed to prove the accident caused her impairments, which were consistent with her pre-existing arthritic and fibromyalgia conditions.

The Tribunal also rejected the applicant's procedural argument that the insurer failed to provide timely notice of its refusal to pay, finding the insurer complied with the ten-day notice requirement under the Statutory Accident Benefits Schedule.

The applicant sought medical and rehabilitation benefits following a motor vehicle accident, which the respondent denied on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG).

The applicant argued that his physical injuries, including a partial shoulder tear, and psychological impairments, diagnosed as an adjustment disorder, warranted removal from the MIG.

The Tribunal found that the physical injuries were predominantly minor and that the psychological diagnosis was not supported by the psychometric testing or DSM-5 criteria.

The application was dismissed, and no benefits or awards were granted.

The applicant, who was self-employed running a house cleaning business, sought increased Income Replacement Benefits (IRB) following a motor vehicle accident.

The dispute centered on the calculation of post-accident fixed business costs, specifically whether expenses like home office and management fees should be deducted when the applicant was not actively working.

The Tribunal agreed with the respondent insurer's calculation, finding that expenses not actually incurred post-accident should not be included.

The Tribunal also dismissed the applicant's claim for a special award, finding the insurer acted reasonably under section 33 of the Schedule in withholding benefits until the applicant provided requested bank statements to verify her post-accident income.