Eric K. Grossman

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for a physiotherapy treatment plan and a driver/passenger assessment.

The respondent denied the benefits.

The Licence Appeal Tribunal found that the applicant failed to prove the physiotherapy treatment plan was reasonable and necessary, noting a lack of clear goals and timelines for recovery, as well as pre-existing conditions.

The Tribunal also found the driver/passenger assessment was not reasonable and necessary, as a psychological progress report indicated the applicant felt she could manage on her own.

The claims for an award and interest were also dismissed.

The applicant sought statutory accident benefits following a 2016 motor vehicle accident.

The respondent denied treatment plans for chronic pain and psychological assessments, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found the applicant suffered from chronic pain syndrome with functional impairment, removing him from the MIG.

The Tribunal ordered the respondent to pay for the chronic pain and psychological assessments, plus interest, finding them reasonable and necessary.

The applicant's claim for an award for unreasonable delay was dismissed, as the respondent had relied on its section 44 assessors.

The applicant sought various statutory accident benefits after being struck by a detached tire while walking.

The Licence Appeal Tribunal dismissed the application in its entirety, finding that the applicant had fully recovered from his physical injuries and was engaging in 'learned helplessness'.

The Tribunal denied claims for attendant care, assistive devices, occupational therapy, and chiropractic treatments, noting inconsistencies in the applicant's expert evidence and exaggerated assessment fees.

The claim for non-earner benefits was dismissed as time-barred and substantively unproven.

Claims for a special award and interest were also dismissed.

The applicant requested a reconsideration of a decision finding her injuries were predominantly minor and subject to the Minor Injury Guideline limit.

She argued the Tribunal erred by failing to consider a psychological assessment report.

The Tribunal dismissed the request, finding no error in not explicitly referencing every piece of evidence.

The Tribunal noted that even if the report had been explicitly analyzed, it would not have changed the conclusion that the applicant's psychological issues were related to the COVID-19 pandemic and job loss, rather than the accident.

The applicant requested a reconsideration of a Licence Appeal Tribunal decision that denied her claims for income replacement benefits and various medical and rehabilitation benefits following a motor vehicle accident.

The applicant argued the Tribunal made errors of fact and law in assessing her pre-104 week disability test.

The adjudicator dismissed the request, finding that the applicant was merely attempting to relitigate the original hearing by asking the Tribunal to re-evaluate the same evidence.

The adjudicator confirmed that the original decision properly weighed the evidence, including functional capacity assessments and medical reports, and found no significant legal or evidentiary mistake.

The applicant sought statutory accident benefits following a motor vehicle accident, disputing the respondent's denial of three treatment plans for chiropractic, massage, and psychological services.

The Tribunal found that the first treatment plan for physical therapy was reasonable and necessary given the applicant's accident-related sprains and strains.

However, the Tribunal dismissed the remaining treatment plans, finding insufficient evidence to link the ongoing symptoms to the accident rather than pre-existing conditions, and a lack of explanation for additional psychological planning fees.

The applicant was awarded $2,575.22 for the first treatment plan plus interest.

The applicant sought statutory accident benefits following a motor vehicle accident, specifically claiming funding for psychological services and a catastrophic impairment assessment.

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

The Tribunal found that the respondent provided sufficient medical reasons for its denials and complied with the notice requirements under the Schedule.

The Tribunal concluded that the applicant failed to meet his evidentiary burden to prove the treatments and assessments were reasonable and necessary, particularly given the lack of response to prior psychological treatment and the absence of evidence supporting a neurological impairment.

The application was dismissed.

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

The respondent insurer denied the benefits, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found that the applicant failed to prove her physical or psychological injuries warranted removal from the MIG.

The medical evidence did not establish chronic pain syndrome or a psychological condition directly caused by the accident.

Consequently, the disputed treatment plans were deemed not reasonable and necessary, and no interest was payable.

The appellant insurer appealed a Licence Appeal Tribunal decision finding that a binding settlement of tort and accident benefits claims was reached via email following mediation.

Shortly after the email exchange, the plaintiff was killed.

The insurer argued no settlement was reached because the plaintiff had not finalized the structure percentage or signed the settlement disclosure notice.

The Divisional Court dismissed the appeal, holding that the essential terms were agreed upon, the structure percentage was a default minimum, and the right to rescind under consumer protection legislation implies a settlement was already reached.

The Ontario Trial Lawyers Association (OTLA) brought a motion to intervene in an appeal concerning the enforceability of a settlement agreement where the plaintiff died before executing the release and structured settlement documents.

The respondent Estate supported the intervention, while the appellant insurer opposed it.

The Divisional Court granted the motion, finding that the appeal raised broader public law issues and policy concerns regarding personal injury settlements and the Insurance Act, and that OTLA would provide a distinct and useful perspective without causing significant prejudice to the parties.

The insurer appealed a Licence Appeal Tribunal decision finding that the insured's claim for income replacement benefits was not statute-barred, as the termination letter was not clear and unequivocal.

The insured cross-appealed the dismissal of her claim for post-104 week income replacement benefits, arguing the adjudicator failed to consider whether alternative employment was comparable in status and reward.

The Divisional Court dismissed both appeals, holding that the limitation issue was a question of mixed fact and law not subject to appeal, and that the post-104 test under the Schedule does not require alternative employment to be comparable in status and reward.

The respondent insurer requested a reconsideration of a decision awarding the applicant a psychiatric assessment and a chronic pain assessment.

The insurer argued the Tribunal erred by not requiring the applicant to first seek OHIP funding and by failing to apply the statutory monetary caps to the psychiatric assessment.

The Tribunal dismissed the OHIP argument as it was not raised at the initial hearing.

However, the Tribunal agreed it erred in law by not applying the statutory maximums under the Schedule and Guidelines.

The reconsideration was partially granted, and the amount payable for the psychiatric assessment was reduced to $2,200.

The respondent insurer requested a reconsideration of a decision finding that the parties had reached a binding settlement agreement regarding the applicant's accident benefits claims.

The insurer argued that the Tribunal erred in concluding that an email from the mediator constituted minutes of settlement and that an executed Settlement Disclosure Notice was not an essential term.

The Tribunal dismissed the request, finding no significant legal or evidentiary mistake that would have affected the outcome, and held that the insurer was attempting to re-litigate arguments that failed at first instance.

The appellant insurer appealed a Licence Appeal Tribunal decision that refused to deduct the respondent's $120,000 long-term disability settlement from her statutory income replacement benefits.

The insurer argued the settlement represented double recovery for income loss.

The Divisional Court dismissed the appeal, upholding the adjudicator's finding that the lump-sum settlement resolved multiple claims, including extracontractual damages, and could not be strictly allocated as an income replacement benefit under section 7(1) of the Statutory Accident Benefits Schedule.

The applicant was involved in two motor vehicle accidents and reached a global settlement with the respondent insurer at mediation.

Ten days later, before signing the settlement disclosure notice (SDN) and release, the applicant was killed by her mother.

The insurer argued the settlement was unenforceable because the applicant did not personally sign the SDN and release, and because the common law slayer rule prevented the funds from flowing to the mother.

The Tribunal found that a binding settlement was reached at mediation and that the applicant's estate could execute the SDN and release on her behalf.

The Tribunal also found that the slayer rule did not invalidate the settlement, as the family committed to ensuring the funds would flow only to the applicant's sister.

The applicant was severely injured when the ATV he was driving collided with a dirt bike on private property.

He sought statutory accident benefits from the respondent insurer, who denied the claim on the basis that the incident did not meet the definition of an "accident" under the Schedule because neither vehicle was an "automobile".

The Tribunal found that the owner of the ATV was not an occupier of the private property where the collision occurred.

Consequently, the ATV was required to be insured under section 15 of the Off-Road Vehicles Act, bringing it within the definition of an "automobile" under the Insurance Act.

The Tribunal concluded that the incident was an "accident" and the applicant was entitled to claim benefits.

The applicant requested a reconsideration of a Licence Appeal Tribunal decision that denied her claim for a $2,738.00 medical benefit for chiropractic services.

The applicant argued the Tribunal failed to consider important medical evidence and erred in fact by suggesting chiropractic treatment was not recommended.

The Vice Chair found no errors of law or fact in the original decision, noting the adjudicator properly considered and weighed the medical evidence.

The request for reconsideration was dismissed.

The appellant appealed a Licence Appeal Tribunal decision denying claims for physiotherapy and an in-home assessment under the Statutory Accident Benefits Schedule.

The insurer had failed to respond to the treatment plans within the required 10-day period under s. 38(8).

The Divisional Court held that the adjudicator erred by requiring the expenses to be reasonable and necessary, as s. 38(11) mandates payment for expenses incurred during the default period and acts as consumer protection legislation.

The appeal was allowed, the insurer was ordered to pay the in-home assessment and applicable physiotherapy expenses, and the issue of a special award was remitted to a new adjudicator.

The applicant sought statutory accident benefits after tripping over a forklift tine while walking towards her parked vehicle and using her key fob to unlock it.

The respondent denied the claim on the basis that the incident was not an 'accident' under s. 3(1) of the Statutory Accident Benefits Schedule.

The Tribunal found that the incident did not meet the purpose test, as walking towards a vehicle and unlocking it with a key fob does not constitute the use or operation of an automobile.

Furthermore, the Tribunal found that the causation test was not met, as tripping over the forklift tine was an intervening act that broke the chain of causation.

The application was dismissed.

The applicant sought statutory accident benefits for the prescription medication Saxenda, arguing that her type 1 diabetes was triggered by emotional stress following a motor vehicle accident.

The adjudicator found that the applicant failed to prove on a balance of probabilities that the accident caused her diabetes, as her own medical expert could not determine the exact initiation of the condition.

In the alternative, the adjudicator held that the applicant failed to prove the medication was reasonable and necessary, noting it was an off-label treatment for weight loss and no evidence of her body mass index was provided.

The application was dismissed.