David Raposo

The applicant was involved in a motor vehicle accident in April 2016 but did not notify the respondent insurer or submit an application for accident benefits until June 2019, over three years later.

The respondent denied the claim due to the delay.

In a preliminary issue hearing, the Tribunal considered whether the applicant had a reasonable explanation for the delay under section 34 of the Statutory Accident Benefits Schedule.

The Tribunal found that the applicant failed to provide a reasonable explanation, noting he had legal representation for his long-term disability claim shortly after the accident and that ignorance of the law is not a reasonable excuse.

The application was dismissed as statute-barred.

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

The insurer raised a preliminary issue, arguing the applicant was barred from proceeding with her application because she failed to attend a requested psychiatric insurer's examination to assess her entitlement to post-104-week income replacement benefits.

The Tribunal found that the insurer's request for the examination was reasonable and necessary due to a change in circumstances, including the death of the applicant's son and the different statutory test for post-104 benefits.

Because the applicant failed to attend the examination, she was barred from proceeding with her application under section 55(1)(2) of the Schedule.

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

The insurer denied funding for physiotherapy, chiropractic treatment, and a psychological assessment, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found that the applicant suffered from vehicular anxiety, a psychological injury that removed him from the MIG.

However, the physical treatment plans were denied as there was no evidence of physical injury.

The psychological assessment was approved subject to the $2,000 statutory limit.

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

The Licence Appeal Tribunal found the chiropractic treatment plan to be reasonable and necessary, noting improvements in the applicant's range of motion and ongoing impairments.

However, the Tribunal found it lacked jurisdiction to deal with the merits of the IRB claim because the benefit was suspended due to the applicant's failure to comply with a section 33 request for financial documents.

The applicant was awarded the treatment plan with interest.

The applicant sought statutory accident benefits for physiotherapy and various assessments following a motor vehicle accident.

The respondent denied the claims on the basis that the treatments were not reasonable and necessary.

The Tribunal dismissed the application, finding that the applicant failed to meet the burden of proof.

The Tribunal entirely rejected the applicant's occupational therapy expert report, finding the assessor was biased, partisan, and provided opinions outside the scope of their expertise.

As no benefits were payable, the claim for interest was also dismissed.

The applicant was involved in a motor vehicle accident in New York and elected to receive New York no-fault benefits.

She later applied to the Licence Appeal Tribunal for Ontario statutory accident benefits, arguing her initial election was invalid because the insurer failed to provide sufficient information under section 32 of the Schedule.

The Tribunal found the insurer complied with its obligations to provide appropriate forms and a written explanation of benefits, and was not required to provide legal advice on which jurisdiction to choose.

The election was deemed valid and binding, precluding the applicant from re-electing Ontario benefits.

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

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

The applicant argued for removal from the MIG due to pre-existing conditions, chronic pain, and psychological injuries.

The Tribunal found that the applicant failed to provide compelling evidence to establish any of these exceptions, preferring the objective evidence of the insurer's examiners over the applicant's self-reported symptoms and clinical impressions.

The Tribunal also dismissed the claim for Income Replacement Benefits, finding insufficient evidence of a substantial inability to perform the essential tasks of pre-accident employment.

The appeal was denied.

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

The insurer denied several treatment plans and non-earner benefits on the basis that the injuries fell within the Minor Injury Guideline (MIG) and requested section 44 insurer's examinations (IEs).

The applicant refused to attend the IEs, arguing that an insurer cannot compel an IE specifically to determine the applicability of the MIG.

The Tribunal held that determining whether an impairment falls within the MIG is a prerequisite to assessing whether treatment plans are reasonable and necessary, and that section 38(10) permits an insurer to request an IE when it believes the MIG applies.

Because the applicant failed to attend properly scheduled IEs without a reasonable excuse, she is statute-barred from proceeding with her application under section 55(1)2 of the Schedule.

The insurer sought reconsideration of a preliminary issue order that precluded the insured from proceeding with a catastrophic impairment hearing until the insurer conducted two insurer examinations (IEs).

The order included a term allowing the IEs to proceed by paper review if the parties could not agree on conditions for in-person assessments.

The insurer argued this term violated natural justice by placing it at a disadvantage.

The Tribunal denied the reconsideration, finding that the original adjudicator properly balanced the insurer's right to an IE against the potential harm to the insured, and that paper reviews are expressly permitted under the Schedule.

The applicant sought statutory accident benefits following a 2015 motor vehicle accident.

A previous Tribunal decision found the applicant's injuries fell within the Minor Injury Guideline (MIG).

The applicant brought a new application claiming psychological impairments took him out of the MIG, relying on a catastrophic impairment rebuttal report from a psychiatrist.

The Tribunal assigned little weight to the applicant's psychiatric evidence due to inconsistencies with the doctor's own clinical notes and surveillance evidence showing the applicant functioning independently.

The respondent's assessors could not determine impairment levels due to the applicant's lack of credibility and cooperation.

The Tribunal concluded the applicant failed to prove his injuries fell outside the MIG, dismissing the claim for a $4,678.40 psychological treatment plan and interest.

The applicant sought statutory accident benefits for a psychological assessment and a chronic pain assessment following a motor vehicle accident.

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

The Tribunal found that the applicant failed to prove she suffered from a psychological impairment or chronic pain that would remove her from the MIG, preferring the respondent's medical assessments which aligned with the family physician's clinical notes.

The Tribunal also found insufficient evidence that a pre-existing shoulder condition prevented maximal recovery.

The application was dismissed.

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

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

The applicant argued that pre-existing migraines and wrist pain, as well as psychological impairments, removed him from the MIG.

The Tribunal found that the applicant failed to provide compelling evidence that his pre-existing conditions would prevent maximal recovery under the MIG limits.

Furthermore, the applicant was precluded from relying on his psychological assessment to escape the MIG because he failed to attend the scheduled section 44 insurer's examinations.

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

The applicant sought statutory accident benefits 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 she should be removed from the MIG due to psychological injuries, a pre-existing psychological condition, and chronic pain.

The Tribunal found the applicant's claims of psychological injury and chronic pain were not credible due to significant inconsistencies in her self-reporting to various medical assessors.

The Tribunal concluded the applicant's injuries were predominantly minor and governed by the MIG, dismissing her application for additional medical benefits and interest.

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

The respondent insurer suspended the IRBs for a seven-week period, alleging the applicant failed to comply with an insurer's examination (IE) when he objected to the exclusion of his wife and the presence of a transcriptionist.

The Tribunal found that the applicant had a reasonable explanation for his non-compliance, given his psychological difficulties, his expectation based on past IEs that his wife could attend, and his good-faith efforts to resolve the issue at the time.

The Tribunal ordered the respondent to pay the withheld IRBs with interest, but dismissed the applicant's claim for a special award, finding the insurer's actions were not unreasonable.

The applicant requested a reconsideration of a Licence Appeal Tribunal decision that dismissed his claim for an income replacement benefit (IRB) following a motor vehicle accident.

The applicant argued the Tribunal erred by refusing to consider medical evidence generated more than 104 weeks after the accident.

The Executive Chair agreed that the Tribunal misinterpreted the case law and erred in excluding the post-104 week evidence, as such evidence can be relevant to determining whether the applicant suffered a substantial inability to perform essential tasks within the first 104 weeks.

However, the Executive Chair found the error was inconsequential because the post-104 week evidence did not establish the required connection between the accident and the impairments.

The request for reconsideration was denied.

The applicant was seriously injured in a motor vehicle accident and sought statutory accident benefits, including non-earner benefits, attendant care benefits, and medical/rehabilitation benefits.

The insurer terminated benefits based on insurer examinations concluding the applicant had reached maximum medical improvement.

The Tribunal found the applicant's ongoing pain and psychological impairments continuously prevented her from engaging in substantially all of her pre-accident activities, entitling her to non-earner benefits.

The Tribunal also determined the reasonable and necessary quantum of attendant care benefits and ordered a 5 percent award against the insurer for unreasonably delaying payment of medical and rehabilitation expenses.

The applicant sought accident benefits for psychological counselling after a previous application was dismissed on the basis that their injuries fell within the Minor Injury Guideline (MIG).

The respondent insurer brought a motion to dismiss the new application, arguing it was barred by res judicata.

The Tribunal dismissed the motion as premature, noting that the specific claim for psychological services was not part of the first application, the determination of whether injuries fall within the MIG is not static, and the matter had not yet proceeded to a case conference to identify the issues and exchange disclosure.

The applicant was injured in a motor vehicle accident as a pedestrian on her second day of a new job.

She applied for an income replacement benefit (IRB).

The insurer accepted entitlement but calculated the weekly benefit at $33.70 based on her earnings of $192.53 over the two days worked prior to the accident.

The applicant disputed the calculation, arguing it was unfair given her short tenure before the accident.

The Tribunal found that the insurer correctly applied the calculation provisions in sections 4 and 7 of the Statutory Accident Benefits Schedule, and that fairness could not override the clear legislative formula.

The weekly IRB was confirmed at $33.70.

The applicant sought an income replacement benefit (IRB) following a motor vehicle accident.

The insurer raised a preliminary issue that the applicant failed to apply for the benefit within 104 weeks of the accident.

The Tribunal found that the applicant did submit a completed disability certificate within the 104-week period, satisfying the application requirement.

However, on the substantive issue, the Tribunal dismissed the claim because the applicant failed to provide sufficient medical evidence demonstrating a substantial inability to perform the essential tasks of his employment during the first 104 weeks, which is a prerequisite for claiming post-104 week IRBs.

The appellant appealed a decision of the License Appeal Tribunal which found that his injuries from a motor vehicle accident fell within the Minor Injury Guideline under the Statutory Accident Benefits Schedule.

The adjudicator preferred the objective medical evidence of the respondent's experts over the self-reported evidence of the appellant's treating physicians, noting credibility issues with the appellant.

The Divisional Court held that the adjudicator properly applied the law and that the decision was reasonable.

The appeal was dismissed with costs fixed at $5,000.