Dr. David Simon

The applicant, who was deemed catastrophically impaired following a 2015 motor vehicle accident, sought payment for several treatment plans denied by the respondent insurer.

The Licence Appeal Tribunal found that the proposed physiotherapy services were not reasonable and necessary, as the applicant had reached maximum medical recovery and previous treatment yielded no functional gains.

The Tribunal partially approved the psychological services plan for the OCF-18 completion fee but denied administrative and planning costs.

The Tribunal approved the occupational therapy and case management plans, finding the requested hours for documentation and planning to be reasonable.

The applicant's claim for a special award was dismissed, as the insurer's conduct was not found to be unreasonable.

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

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

The applicant contended that a right shoulder injury requiring surgery warranted removal from the MIG.

The Tribunal found that the applicant failed to prove the shoulder injury was caused by the accident, noting a two-year delay in reporting the pain and medical records suggesting a workplace injury.

As the applicant remained within the MIG and the limits were exhausted, the claims for treatment plans, attendant care, interest, and an award were dismissed.

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

The Licence Appeal Tribunal found the applicant was entitled to reduced amounts for yoga therapy, occupational therapy services, and an attendant care needs assessment, finding them reasonable and necessary for symptom management and functional improvement.

The Tribunal denied claims for chiropractic and physiotherapy treatment, finding the applicant had reached maximum medical recovery for orthopaedic injuries.

The Tribunal also declined to order a special award under s. 10 of Regulation 664, finding the insurer's conduct was not excessive or imprudent.

The applicant sought a catastrophic impairment designation and attendant care benefits following a motor vehicle accident.

The Tribunal evaluated the competing multidisciplinary assessments to determine if the applicant met the 55% whole person impairment threshold under Criterion 7.

The Tribunal rejected several of the applicant's proposed impairment ratings, including those for the lumbar spine, headaches, mental status, and medication, finding them inconsistent with the AMA Guides and medical evidence.

The Tribunal concluded the applicant's combined whole person impairment was 45%, falling short of the catastrophic impairment threshold.

The application for benefits, interest, and costs was dismissed.

The applicant, a self-employed taxi driver, sought income replacement benefits (IRBs) and a medical benefit for physiotherapy following a motor vehicle accident.

The insurer denied the benefits, relying on surveillance and multidisciplinary assessments that focused primarily on physical impairments.

The Tribunal found that the applicant suffered severe and ongoing psychological impairments, including major depressive disorder and post-traumatic stress disorder, which rendered him substantially unable to perform the essential tasks of his employment for the first 104 weeks, and completely unable to engage in any suitable employment thereafter.

The Tribunal awarded the claimed IRBs and interest.

Furthermore, the Tribunal ordered a 50% lump sum award under O. Reg. 664, finding that the insurer unreasonably withheld benefits by repeatedly ignoring the psychological diagnoses provided by its own assessors.

The claim for physiotherapy was dismissed for lack of evidence.

The applicant, an 18-year-old pedestrian, suffered a severe traumatic brain injury when struck by a car.

He applied for non-earner benefits, which the respondent insurer denied based on insurer examinations suggesting symptom exaggeration.

The Licence Appeal Tribunal found that the applicant suffered a complete inability to carry on a normal life, noting his inability to return to school, drive, play basketball, or maintain his pre-accident social life.

The Tribunal rejected the insurer's neuropsychological assessments as they were contradicted by the insurer's own catastrophic impairment assessors, who found genuine, severe cognitive deficits.

The Tribunal ordered the payment of non-earner benefits and granted a special award of 40% under Regulation 664, finding the insurer acted unreasonably by maintaining its denial despite its own catastrophic assessors' reports.