Kelly-Ann Smith

The applicant was involved in a motor vehicle accident and sustained a severe traumatic brain injury.

He applied to the Licence Appeal Tribunal after the respondent insurer denied his claims for catastrophic impairment, post-104 week income replacement benefits, and various treatment plans.

The Tribunal found that the applicant sustained a catastrophic impairment under Criterion 4, as his GOS-E assessment demonstrated a Lower Moderate Disability due to his inability to work and constant disruption to relationships.

The Tribunal also awarded post-104 week income replacement benefits, finding the applicant completely unable to engage in suitable employment due to cognitive and emotional impairments.

The claims for treatment plans were dismissed as the applicant failed to make submissions on their reasonableness and necessity.

The applicant sought post-104 income replacement benefits and a physiotherapy treatment plan following a low-speed motor vehicle accident.

The Tribunal found that the applicant's physical, psychological, and pain complaints did not render her completely unable to engage in employment for which she is reasonably suited, such as customer service or hairstyling.

The Tribunal preferred the evidence of the respondent's assessors and contemporaneous medical records over the applicant's experts.

The treatment plan was denied as past similar treatments had not been effective.

The application was dismissed.

The applicant sought a determination that he sustained a catastrophic impairment under Criterion 8 of the Schedule and claimed entitlement to a post-104 income replacement benefit (IRB) following a motor vehicle accident.

The Tribunal found that the applicant did not meet the threshold for catastrophic impairment, as he did not demonstrate a marked impairment in at least two of the four functional domains, specifically finding his social functioning was compatible with some useful functioning.

However, the Tribunal granted the applicant's claim for a post-104 IRB, finding that the combination of his physical, psychological, cognitive, and visual impairments resulted in a complete inability to engage in any employment for which he was reasonably suited by education, training, or experience.

Interest was awarded on the overdue IRB payments.

The applicant sought post-104-week income replacement benefits following a motor vehicle accident.

The respondent initially approved the benefits but denied them four days later based on the same Insurer's Examination reports.

The Tribunal found that the respondent's denial was a correction of the initial approval and that the applicant failed to prove a complete inability to engage in any employment for which he was reasonably suited.

The applicant's expert reports were given little weight due to a lack of objective testing and failure to outline functional limitations.

The claim for income replacement benefits and interest was dismissed.

However, the Tribunal awarded the applicant $500 in costs because the respondent breached a case conference report and order by producing documents 137 days late, which interfered with the efficiency of the dispute resolution process.

The applicant insurer sought repayment of $85,181.38 in income replacement benefits (IRBs) paid to the respondent following a 2010 motor vehicle accident.

The insurer alleged the respondent engaged in willful misrepresentation by working post-accident while denying employment to assessors.

The Tribunal found it had jurisdiction to hear the dispute and concluded the respondent willfully misrepresented his employment status.

As the respondent failed to provide evidence to calculate the exact quantum of repayment, the Tribunal ordered the full amount of $85,181.38 to be repaid, plus interest.

The applicant sought a determination of catastrophic impairment and entitlement to income replacement benefits (IRB), attendant care benefits (ACB), and various treatment plans following a 2018 motor vehicle accident.

The Tribunal found the applicant did not meet the 55% whole person impairment threshold under Criterion 7, concluding his combined physical and mental impairment rating was 40%.

The Tribunal also found the applicant failed to prove a complete inability to engage in suitable employment, dismissing the claim for post-104-week IRB.

As the applicant was not catastrophically impaired and had exhausted non-catastrophic limits, the claims for ACB and treatment plans were also dismissed.

The applicant sought ongoing income replacement benefits (IRBs) more than 104 weeks after a motor vehicle accident, claiming a complete inability to work due to chronic pain and psychological impairments.

The respondent insurer terminated IRBs based on insurer examinations indicating the applicant could perform alternative employment.

The Licence Appeal Tribunal found that the applicant's condition had improved, she had reached maximum medical improvement, and she possessed transferable skills suitable for roles such as a beauty salon attendant or cashier.

The Tribunal concluded the applicant failed to meet the post-104 week disability test.

Additionally, the applicant's claim for the cost of a chronic pain assessment was denied because it was incurred before submitting a treatment plan, contrary to section 38(2) of the Schedule.

The application was dismissed.

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

The Licence Appeal Tribunal found the applicant suffered a complete inability to engage in any employment for which he was reasonably suited, entitling him to a post-104 week income replacement benefit.

The Tribunal also determined the applicant sustained a catastrophic impairment, as his combined physical, neurocognitive, and mental/behavioural impairments met the 55% whole person impairment threshold under the AMA Guides.

However, the applicant's claims for specific medical and rehabilitation benefits were dismissed for lack of evidence proving they were reasonable and necessary.