David Raposo

The applicant sought reconsideration of a Tribunal decision that found his claim for an income replacement benefit was barred by the two-year limitation period under section 56 of the Statutory Accident Benefits Schedule.

The applicant argued that the insurer failed to provide adequate notice of his right to dispute the denial and that the insurer's post-denial conduct created an estoppel.

The Executive Chair rejected these arguments, finding that the Explanation of Benefits provided sufficient notice and that a subsequent notice of examination did not reset the limitation period.

The request for reconsideration was denied.

The applicant was injured in a motor vehicle accident and received income replacement benefits until they were terminated by the insurer.

The applicant disputed the termination but filed the application with the Licence Appeal Tribunal outside the two-year limitation period under section 56 of the Statutory Accident Benefits Schedule.

The adjudicator rejected the applicant's arguments that the insurer's notice was invalid, that the jurisdictional transfer from FSCO to the Tribunal justified relaxing the limitation period, and that the insurer should be estopped from relying on the limitation period.

The claim was dismissed as statute-barred.

The Applicant sought payment for three chiropractic treatment plans and non-earner benefits following a 2015 motor vehicle accident.

The insurer denied the claims on the basis that the Applicant's injuries fell within the Minor Injury Guideline (MIG) and were not reasonable and necessary.

The Tribunal found the Applicant lacked credibility due to inconsistent statements about his employment and failure to disclose a prior 2013 accident with similar injuries.

The Tribunal accepted the insurer's independent medical examinations, concluding the Applicant failed to prove his impairments were directly caused by the 2015 accident or that he met the test for non-earner benefits.

The appeal was dismissed entirely.

The applicant was injured in two motor vehicle accidents and sought payment for six treatment plans for chiropractic services and massage therapy.

The respondent insurer denied the treatment plans, arguing the injuries were minor and did not require further facility-based treatment, relying on surveillance evidence and an independent medical examination.

The adjudicator found that the applicant suffered a chronic impairment to her thoracic spine and that the proposed treatments were reasonable and necessary to relieve pain and improve function.

The surveillance evidence did not undermine the applicant's credibility regarding her pain.

The insurer was ordered to pay for all six treatment plans.

The applicant was injured in a motorcycle accident and received income replacement benefits.

The insurer suspended benefits after the applicant refused to attend an insurer's examination, arguing the insurer failed to provide valid 'medical and any other reasons' as required by section 44 of the Statutory Accident Benefits Schedule.

The Tribunal found that the insurer's stated reasons—to determine timelines for recovery and future prognosis—were valid, given the applicant's ongoing treatment and potential need for surgery.

Consequently, the applicant was precluded from receiving benefits during the period of non-compliance, and his claim for a special award was dismissed.

Following the dismissal of the applicant's application for arbitration on a preliminary issue, the insurer sought its expenses of the proceeding.

The arbitrator found the insurer was entitled to its expenses as the successful party.

The arbitrator reduced the insurer's claimed legal fees, finding the involvement of four lawyers and a law clerk for a straightforward limitation period issue to be excessive and duplicative.

The insurer was awarded $3,459.39 in total expenses, inclusive of fees, disbursements, and HST.

The applicant insurer sought an order compelling seven respondents to attend examinations under oath regarding their statutory accident benefits claims, specifically attendant care benefits, due to concerns about validity.

The respondents refused, citing insufficient notice of the reasons for examination and their medical conditions.

The court dismissed the motion, holding that the insurer's generic notice ("determining whether State Farm is liable to pay benefits") was inadequate under s. 33(4)3 of the Statutory Accident Benefits Schedule.

The court emphasized that specific reasons for the examination are a condition precedent to the obligation to attend, allowing insureds to prepare adequately.

The applicant was injured in a motor vehicle accident and sought caregiver and non-earner benefits.

The insurer denied the benefits and later raised a preliminary issue that the applicant was statute-barred from proceeding to arbitration because she failed to apply for mediation within the two-year limitation period.

The arbitrator found that the insurer provided a valid, clear, and unequivocal notice of stoppage of benefits, which triggered the limitation period.

Because the applicant applied for mediation more than three years after the denial, the application for arbitration was dismissed as time-barred.

The applicant insurer appealed an arbitrator’s decision concerning loss transfer reimbursement under s. 275 of the Insurance Act after paying statutory accident benefits to its insured following a motorcycle accident caused by the respondent insurer’s insured.

The arbitrator concluded that the applicant insurer had grossly mishandled the accident benefits file and unreasonably paid substantial benefits, including delayed insurer examinations and excessive settlement amounts.

As a result, the arbitrator reduced the amount recoverable from the respondent insurer.

The court held that the arbitrator’s findings involved mixed fact and law and were entitled to deference unless unreasonable.

Finding ample evidence supporting the arbitrator’s conclusions, the court declined to interfere and upheld the reduced indemnity award.

The appellant sought leave to appeal a preliminary arbitration order requiring him to attend two insurer medical examinations (IMEs) to assess his entitlement to post-104 week income replacement benefits.

The Director's Delegate declined to exercise discretion under Rule 50.2 of the Dispute Resolution Practice Code to accept the appeal.

The Delegate found that the arbitrator's decision was a preliminary procedural order, and accepting the appeal would add expense and delay rather than facilitate a cost-effective resolution.

The arbitrator had properly considered the relevant criteria for IME requests, including the change in the disability test and procedural fairness, and the appeal did not raise novel or important issues warranting intervention.

The insurer brought a motion to compel the insured to attend orthopaedic and psychological assessments to determine ongoing entitlement to income replacement benefits after the 104-week mark.

The insured opposed, arguing the assessments were merely to bolster the insurer's case at arbitration.

The arbitrator found that the change in the entitlement test post-104 weeks constituted a change in circumstances, giving the insurer a prima facie right to the assessments.

The motion was granted, and the arbitration was ordered stayed if the insured failed to attend the scheduled assessments.

The plaintiffs sued their insurer for terminating statutory accident benefits based on reports from health care professionals retained by the insurer under s. 42 of the Statutory Accident Benefits Schedule.

On discovery, the plaintiffs sought to ask questions that amounted to cross-examining these experts.

The motion judge held that the experts were not 'experts' within the meaning of Rule 31.06(3) of the Rules of Civil Procedure, and thus the prohibition against cross-examination did not apply.

The Divisional Court allowed the insurer's appeal, holding that the clear wording of Rule 31.06(3) covers experts engaged by a party for a purpose other than litigation, including s. 42 assessors.

The defendant insurer sought leave to appeal a decision upholding a Master's order that required a claims examiner to answer certain questions on discovery.

The questions related to whether health professionals who assessed the plaintiffs under s. 42 of the Statutory Accident Benefits Schedule had requested certain records.

The appeal judge had found that these professionals were 'assessors' rather than 'experts' under rule 31.06(3), and thus the prohibition against cross-examining experts on discovery did not apply.

The Divisional Court granted leave to appeal, finding that the issue of whether rule 31.06(3) applies to s. 42 assessors is open to serious debate and raises a new question of principle.