Statutory Accident Benefits Schedule matters (SABS)

The applicant tripped in a pothole and fell while walking towards her parked minivan in a parking lot.

She applied for statutory accident benefits, claiming the incident was an 'accident' under section 3(1) of the Schedule.

The Tribunal applied the two-part purpose and causation test and found that walking towards a parked car does not satisfy the purpose test.

Furthermore, the pothole was an intervening act that directly caused the injuries, breaking the chain of causation.

The application was dismissed.

The applicant sought medical benefits and the cost of a psychological assessment following a motor vehicle accident.

The Licence Appeal Tribunal found that one treatment plan was statute-barred as the application was brought more than two years after the denial.

Other treatment plans were denied because the applicant failed to prove they were reasonable and necessary, lacking contemporaneous medical evidence.

Two treatment plans that the respondent conceded were approved were found payable.

The claim for the psychological assessment was dismissed as the applicant made no submissions on it.

Interest was awarded on any overdue payments for the approved plans.

The insurer requested a reconsideration of two Licence Appeal Tribunal decisions which found that its notices denying treatment plans were defective under ss. 38(8) and (9) of the Statutory Accident Benefits Schedule.

The Tribunal had concluded that the defective notices triggered the mandatory consequences of s. 38(11), prohibiting the insurer from ever taking the position that the applicants' impairments fell within the Minor Injury Guideline (MIG) and requiring the insurer to pay for the treatment plans.

On reconsideration, the Executive Chair upheld the Tribunal's interpretation that the MIG prohibition applies to the entire claim and that s. 38(11)2 requires payment without a "reasonable and necessary" analysis.

However, the Executive Chair found an error regarding the quantum awarded to one applicant, as the insurer had subsequently provided a compliant notice that limited its obligation to pay.

The reconsideration was granted in part to reduce the quantum for that applicant, and otherwise denied.

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

After failing to attend an initial case conference, the applicant and his counsel failed to attend the reconvened case conference despite being warned that failure to appear could result in dismissal.

The respondent moved to dismiss the application.

The adjudicator granted the motion and dismissed the application for abandonment under Rule 3.4 of the Licence Appeal Tribunal Rules of Practice and Procedure.

The applicant sought statutory accident benefits, including income replacement and housekeeping benefits, following a motor vehicle accident.

At the outset of the hearing before the Licence Appeal Tribunal, the parties entered into settlement negotiations and resolved all outstanding issues.

The Tribunal closed its file.

The applicant brought a motion to adjourn a scheduled three-day hearing regarding non-earner and attendant care benefits.

The applicant had recently served an Application for Determination of Catastrophic Impairment (OCF-19) and argued that proceeding with the hearing before the catastrophic impairment issue was resolved could result in a multiplicity of proceedings.

The respondent opposed the adjournment, citing delay.

The adjudicator granted the adjournment, finding that the delay in serving the OCF-19 was justified by the need for medical testing, and that adjourning the hearing would avoid duplicative proceedings and allow for a full and fair hearing on the merits.

The applicant sought income replacement benefits and medical benefits following a motor vehicle accident.

The respondent raised preliminary issues regarding the applicant's failure to attend a physiatry insurer examination (IE) and failure to provide information under section 33 of the Schedule.

The Tribunal held that the applicant is barred from proceeding with her IRB claim until she attends the physiatry IE, as the respondent's request was reasonably necessary.

However, the Tribunal found that the applicant had provided sufficient information and documentation to the respondent, meaning her claim was not barred under section 33.

Neither party was awarded costs.

The applicant sought statutory accident benefits after tripping on an uneven curb shortly after disembarking from a vehicle.

The respondent denied the claim, arguing the incident did not meet the definition of an 'accident' under the Schedule.

The Tribunal found that the use or operation of the vehicle was not the direct cause of the injuries, as the chain of causation was broken by an intervening act—the uneven curb.

The application was dismissed, and the respondent's request for costs was denied.

The applicant sought reconsideration of a Licence Appeal Tribunal decision denying her claim for an income replacement benefit following a motor vehicle accident.

The applicant argued that the Tribunal misapplied the test for eligibility, failed to state the standard of proof, and improperly considered certain evidence.

The Executive Chair dismissed the request for reconsideration, finding that the Tribunal correctly concluded the applicant was not working due to a temporary layoff rather than a substantial inability to perform her pre-accident employment.

The Chair also found no error in the Tribunal's application of the standard of proof or its treatment of the evidence.

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

The insurer denied the claims, arguing the injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found that the applicant's pre-existing conditions, including knee osteoarthritis and abdominal issues, as well as a post-accident chronic pain diagnosis, removed her from the MIG.

The Tribunal ordered the insurer to pay for multiple treatment plans and a chronic pain assessment, finding them reasonable and necessary, but denied the cost of a medical bracelet and the applicant's request for costs.

The applicant sought a medical benefit of $2,000 for psychological services following a motor vehicle accident.

The Tribunal dismissed the claim, finding that the applicant's self-reporting to her own experts was inconsistent with her statements during the insurer's examination.

The Tribunal preferred the evidence of the insurer's expert, who concluded that the applicant did not suffer from a psychological impairment requiring formal services.

The applicant's request for costs was also denied as it was unsupported by evidence or argument.

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

The Licence Appeal Tribunal found the applicant suffered a complete inability to engage in any employment for which he was reasonably suited, entitling him to a post-104 week income replacement benefit.

The Tribunal also determined the applicant sustained a catastrophic impairment, as his combined physical, neurocognitive, and mental/behavioural impairments met the 55% whole person impairment threshold under the AMA Guides.

However, the applicant's claims for specific medical and rehabilitation benefits were dismissed for lack of evidence proving they were reasonable and necessary.

The applicant sought medical benefits for occupational therapy assessments following a motor vehicle accident.

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

The applicant argued the insurer's denial letters failed to comply with the notice requirements under section 38(8) of the Schedule.

The Tribunal found the denial letters were compliant.

Furthermore, the Tribunal concluded the applicant failed to prove his injuries fell outside the MIG.

Consequently, the claim for an in-home assessment was barred by section 25(2) of the Schedule, and the claim for a work site assessment was dismissed for lack of evidence that it was reasonable and necessary.

The applicant sought statutory accident benefits following a motor vehicle accident, claiming chronic pain and psychological impairments removed him from the Minor Injury Guideline (MIG).

The Licence Appeal Tribunal found the applicant's injuries were predominantly minor, noting inconsistencies in the applicant's expert reports and preferring the thoroughness of the insurer's examinations.

As the injuries fell within the MIG, the applicant was not entitled to attendant care benefits or the disputed medical and examination expenses.

The application was dismissed, and the respondent's request for costs was denied.

The respondent brought a motion to dismiss the application without a hearing, arguing the applicant abandoned the proceeding by failing to attend a scheduled case conference.

The respondent also sought costs, alleging the applicant's conduct was unreasonable and vexatious.

The Tribunal dismissed the motion, finding the applicant's attendance at the motion hearing and his affidavit evidence of a mental breakdown demonstrated he had not abandoned his claim.

The Tribunal also declined to award costs, accepting the applicant's explanation for his absence and finding his conduct was not intended to harass or show disrespect.

The applicant filed a motion to combine his appeal for ongoing statutory accident benefits with the insurer's appeal for the repayment of income replacement benefits based on material misrepresentation.

The Tribunal dismissed the motion, finding that the issues were distinct and required separate evidentiary bases.

The Tribunal also noted that consolidating the files would prejudice the insurer by delaying its already scheduled hearing and causing the loss of expenditures incurred for that hearing.

The applicant brought a motion to combine his appeal for the denial of ongoing income replacement and other benefits with the insurer's earlier appeal for the repayment of income replacement benefits based on material misrepresentation.

The insurer opposed the motion, arguing that consolidation would require adjourning an already scheduled hearing for which it had incurred costs.

The Tribunal dismissed the motion, finding no efficiency in consolidating the files because the issues were distinct and required separate evidentiary bases.

The Tribunal also noted that consolidation would prejudice the insurer's right to an expeditious determination of its repayment applications.

The applicant sought non-earner benefits following a motor vehicle accident, claiming a complete inability to carry on a normal life.

The Tribunal reviewed the applicant's pre-accident life, noting significant pre-existing health conditions and mobility restrictions.

The Tribunal found that post-accident, the applicant continued to engage in substantially all of the activities she ordinarily engaged in before the accident, such as household chores, shopping, and family vacations, albeit with some modifications and assistance.

Consequently, the application for non-earner benefits was dismissed.

The respondent brought a motion to exclude a medical report filed by the applicant after the deadline set in a case conference order.

The applicant argued the report was merely supplementary to an earlier report.

The Tribunal found that admitting the report without allowing the respondent to respond would be prejudicial.

To balance the applicant's right to present her case with the respondent's right to procedural fairness, the Tribunal granted the motion in part by adjourning the hearing to allow the respondent to have the applicant assessed and to respond to the late report.

The applicant, a minor, sought payment for a psychological assessment following a motor vehicle accident.

The respondent insurer denied the claim on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG) and the $3,500 limit had been nearly exhausted.

The adjudicator found that the applicant failed to meet the burden of proving her injuries fell outside the MIG, as the medical evidence, including reports from her family physician and the respondent's assessors, indicated only minor injuries such as strains and contusions.

The claim for the psychological assessment was dismissed.

The respondent's request for costs was also denied, as there was no evidence the applicant acted frivolously or in bad faith.