Fabio Salerno

The applicant sought statutory accident benefits following a motor vehicle accident, including an income replacement benefit (IRB) and funding for chiropractic, physiotherapy, and psychological treatment plans.

The respondent denied the benefits, relying on insurer's examinations which concluded the applicant did not suffer a substantial inability to perform his pre-accident employment and that the proposed treatments were not reasonable and necessary.

The adjudicator found that the applicant failed to provide sufficient medical evidence to meet his burden of proof for the IRB and the treatment plans.

The adjudicator also dismissed the claims for interest and an award for unreasonable delay, as no benefits were found to be overdue or unreasonably withheld.

The application was dismissed in its entirety.

The applicant sought statutory accident benefits for psychological services following a motor vehicle accident.

The respondent insurer denied portions of four treatment plans, arguing that the first plan was barred by the two-year limitation period and that the hourly rate requested for a social worker in the subsequent plans was unreasonable.

The Tribunal found that the limitation period was not triggered for the first plan because the insurer's initial notice of denial was unclear and non-compliant.

However, the Tribunal dismissed the claims on the merits, finding that the applicant failed to provide objective medical evidence to support the first treatment plan and failed to prove that the higher hourly rate of $149.61 for a social worker was reasonable compared to the $100.00 rate approved by the insurer.

The application was dismissed in its entirety.

The applicant sought non-earner benefits (NEB) following a motor vehicle accident.

The insurer initially denied the claim but failed to provide sufficient medical or other reasons in its denial letter, violating s. 36(4)(b) of the Schedule.

The Tribunal found the applicant was entitled to NEB for the period between the application and the date a compliant notice was finally provided.

However, the applicant failed to prove a complete inability to carry on a normal life for the remainder of the period, as the medical evidence was largely subjective and inconsistent.

The Tribunal awarded a 10% special award under s. 10 of O. Reg 664 due to the insurer's unreasonable withholding of benefits through defective notice.