Catherine Hilary Zingg

The respondent insurer requested a reconsideration of a Licence Appeal Tribunal decision that awarded the applicant an income replacement benefit (IRB) of $287.88 per week.

The respondent argued the Tribunal erred in its calculation of the applicant's pre-accident income and failed to deduct post-accident Employment Insurance (EI) benefits.

The Vice-Chair granted the reconsideration, finding the original decision lacked an evidentiary basis for its pre-accident income calculation and erred by not deducting the post-accident EI payments.

The decision was varied to award an IRB of $265.24 per week for a reduced period.

The applicant's request for costs was denied.

The applicant sought income replacement benefits (IRBs) following a motor vehicle accident.

The Tribunal found that the applicant suffered an accident-related psychological impairment, specifically an adjustment disorder with mixed anxiety and depressed mood, which caused a substantial inability to perform the essential tasks of her pre-accident employment in customer service.

The Tribunal awarded IRBs in the amount of $287.88 per week for the disputed period, along with interest.

The applicant's claim for an award for unreasonable delay was dismissed, as the insurer's conduct was not found to be excessive or indicative of bad faith.

The applicant sought various medical and rehabilitation benefits following a 2020 motor vehicle accident.

The adjudicator found the applicant was not subject to the Minor Injury Guideline, as the insurer had previously removed her from it.

The applicant was awarded a chronic pain assessment based on her family doctor's records, and the balance of a mental health assessment due to a non-compliant denial notice by the insurer.

Claims for psychological, physiatry, and neurological assessments were dismissed, as was the claim for a special award under s. 10 of Regulation 664.

The applicant sought statutory accident benefits after being struck by a vehicle during a road rage incident.

The respondent insurer denied the claim, arguing the incident was not an 'accident' because the driver intentionally used the vehicle as a weapon.

The Licence Appeal Tribunal applied the purpose and causation tests, finding that the vehicle was in ordinary use and directly caused the applicant's injuries.

The Tribunal held that the driver's criminal conviction for dangerous driving did not break the chain of causation or disentitle the applicant from benefits, concluding the incident met the definition of an accident under section 3(1) of the Schedule.

The applicant sought non-earner benefits (NEBs) following a motor vehicle accident, arguing the insurer failed to properly deny the NEB claim after initially paying income replacement benefits (IRBs).

The Tribunal held that the acceptance and payment of IRBs implied a denial of NEBs, as the two benefits are mutually exclusive under the current Schedule.

Furthermore, the applicant failed to meet the substantive test for NEBs, as evidence demonstrated she had returned to work, drove her own vehicle, and performed housekeeping tasks, meaning she did not suffer a complete inability to carry on a normal life.

The application was dismissed.

An appeal from an arbitration decision under the Insurance Act concerning priority of payment of statutory accident benefits.

The claimant, a 25-year-old who suffered severe traumatic brain injury in a motorcycle accident, was deemed catastrophically impaired.

The arbitrator determined that the claimant was principally dependent on his sister, who was insured by the appellant, rather than on his parents or the motorcycle insurer.

The appeal challenged the arbitrator's application of the dependency test, arguing that the arbitrator failed to properly apply all four criteria from the leading case and failed to conduct a precise calculation of the 51% threshold.

The court upheld the arbitrator's decision, finding no error of law or palpable and overriding error in the arbitrator's reasoning and factual conclusions.

The applicant sought statutory accident benefits following a motor vehicle accident, disputing the respondent's denial of several treatment plans for physiotherapy, psychological services, and an attendant care assessment, as well as a claim for a special award.

The Tribunal found the applicant was not entitled to the physiotherapy plan or the attendant care assessment due to a lack of objective medical evidence demonstrating functional limitations.

However, the Tribunal granted the outstanding balances for four psychological treatment plans, preferring the treating psychologist's recommendation for 1.5-hour sessions over the insurer's 1-hour approvals.

A subsequent psychological treatment plan was denied based on a psychiatric assessment attributing current symptoms to non-accident-related factors.

The claim for a special award was dismissed as the insurer's conduct was not unreasonable.

The applicant sought an income replacement benefit (IRB) and funding for four psychological treatment plans following a motor vehicle accident.

The Licence Appeal Tribunal dismissed the application, finding the applicant failed to prove a substantial inability to perform the essential tasks of his pre-accident employment, noting he had been laid off due to a shortage of work and received regular employment insurance benefits.

The Tribunal also denied the treatment plans, concluding the applicant did not provide sufficient explanation or evidence to justify the outstanding amounts for brokerage, planning, and documentation support services beyond what the insurer had already approved.

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

The Tribunal found the applicant failed to establish that the outstanding balance of the first plan was payable, as he did not justify a higher hourly rate for a psychotherapist or the need for additional brokerage, planning, and documentation services.

The Tribunal also denied the second plan, relying on an insurer's examination report indicating the applicant had reached maximum medical improvement and had no interest in further psychotherapy.

The application was dismissed in its entirety.

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

The applicant passed away prior to the hearing, and no estate trustee was appointed.

The matter proceeded to a written hearing, but no submissions or evidence were filed on behalf of the applicant.

The Tribunal found that the applicant failed to meet the burden of proving entitlement to the claimed benefits.

The application was dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident, disputing the insurer's determination that her injuries fell within the Minor Injury Guideline (MIG).

The applicant argued that a pre-existing knee condition and accident-related chronic pain warranted removal from the MIG.

The Licence Appeal Tribunal found the applicant failed to provide compelling medical evidence that her pre-existing condition prevented recovery within the MIG, and preferred the respondent's physiatrist's evidence that the injuries were soft-tissue in nature.

The Tribunal also dismissed the claim for an income replacement benefit, finding no evidence that the applicant suffered a substantial inability to perform the essential tasks of her pre-accident employment.

The application was dismissed in its entirety.

The applicant sought payment for a psychological treatment plan following a motor vehicle accident.

The respondent partially approved the plan but denied the balance of $4,918.00.

The Tribunal found that the applicant established the reasonableness and necessity of a sound machine and relaxation CD/DVD, awarding $188.00 plus interest.

However, the applicant failed to prove that the remaining balance, which included additional therapy session time, a CES medical device, and virtual reality sessions, was reasonable and necessary.

The applicant sought statutory accident benefits following a motor vehicle accident, including a non-earner benefit, psychological services, an occupational therapy assessment, and out-of-pocket expenses.

The Tribunal found that the applicant was not entitled to the non-earner benefit because she failed to provide sufficient evidence comparing her pre- and post-accident activities to establish a complete inability to carry on a normal life.

The Tribunal also denied the psychological treatment plans because the applicant failed to justify the service providers charging rates higher than those prescribed for psychotherapists in the Professional Services Guideline, and failed to justify transportation costs.

The requests for an occupational therapy assessment, a massage chair, and a flight cancellation fee were also dismissed as not reasonable and necessary or not payable under the Schedule.

Claims for an award and interest were dismissed.

The applicant sought payment for the unapproved balances of three treatment plans for psychological assessment and treatment following a motor vehicle accident.

The respondent had partially approved the plans based on the recommendations of its psychological assessor and the rates set out in the Professional Services Guideline.

The Tribunal found that the applicant failed to provide any evidence to contradict the respondent's assessor or to establish that the unapproved balances were reasonable and necessary.

The application was dismissed.

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

The respondent denied benefits and the applicant applied to the Licence Appeal Tribunal.

The Tribunal found the applicant was barred from proceeding with her claim for post-104 week income replacement benefits due to her failure to attend a reasonably necessary physiatry insurer's examination without a reasonable explanation.

The applicant also failed to prove that any pre-104 week income replacement benefits remained outstanding.

However, the Tribunal found that four of the five disputed treatment plans, including those for physical therapy, therapeutic devices, a home/attendant care assessment, and a driver reintegration assessment, were reasonable and necessary to address the applicant's chronic pain and functional impairments.

A treatment plan for a psychological assessment was denied as duplicative.

The applicant requested a reconsideration of a Tribunal decision that barred her from proceeding with her application due to alleged non-attendance at insurer's examinations.

The applicant argued that the Tribunal failed to consider her preliminary issue reply submissions due to an administrative error.

The Tribunal agreed that the failure to consider the submissions caused an unjust outcome and granted the reconsideration, ordering a new hearing on both the preliminary and substantive issues.

The applicant sought statutory accident benefits following a rear-end motor vehicle collision.

The insurer denied funding for various assessments and psychological treatment, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) and were subject to the $3,500 limit.

The Tribunal found that the applicant suffered from chronic pain causing functional impairment, removing her from the MIG.

The Tribunal ordered the insurer to fund the proposed chronic pain assessment, psychological assessment, and psychological services, finding them reasonable and necessary.

However, the request for MRIs was denied as they were reasonably available under OHIP.

The applicant sought income replacement benefits (IRBs) following a motor vehicle accident, claiming a substantial inability to perform the essential tasks of his self-employment as a shipping company president.

The Tribunal dismissed the application, finding the applicant's medical evidence unpersuasive as it relied heavily on self-reporting, which was undermined by credibility issues and psychological testing suggesting he was feigning symptoms.

The Tribunal preferred the respondent's insurer examination reports, which concluded the applicant suffered only soft-tissue injuries and no substantial inability to work.

Claims for post-104 IRBs, interest, and the respondent's request for costs were also dismissed.

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

The respondent insurer raised a preliminary issue that the applicant was barred from proceeding with her application because she failed to attend multiple scheduled insurer examinations to assess her entitlement to an income replacement benefit.

The Tribunal found that the respondent made numerous reasonable attempts to schedule and accommodate the applicant, who failed to attend without providing a reasonable excuse.

Given the extensive delay of over three years, the Tribunal held that the prejudice to the respondent could not be remedied by rescheduling.

The application was dismissed pursuant to section 55(1)2 of the Schedule.

The applicant sought 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) and the $3,500 limit had been exhausted.

The Tribunal found that the applicant failed to prove on a balance of probabilities that his physical injuries, alleged psychological impairments, pre-existing conditions, or chronic pain warranted removal from the MIG.

As the MIG limit was exhausted, the disputed treatment plans were not payable, and claims for interest and a Regulation 664 award were dismissed.