Ranya Ghatas

The applicant was injured in a motorcycle accident and sought a determination that he sustained a catastrophic impairment under criterion 8 of the Statutory Accident Benefits Schedule due to mental and behavioural disorders.

The respondent denied the claim, arguing the applicant's impairments were moderate and stemmed from pre-existing conditions.

The Tribunal preferred the evidence of the applicant's assessors, finding that the applicant suffered marked impairments in the spheres of activities of daily living, social functioning, concentration, persistence and pace, and adaptation.

The Tribunal concluded the applicant is catastrophically impaired.

The applicant sought accident benefits following a motor vehicle accident, claiming she sustained a catastrophic impairment due to psychological issues.

The Tribunal found that the applicant's extensive pre-existing psychological conditions were the primary cause of her impairments, and the accident was not a necessary cause.

The Tribunal preferred the respondent's medical evidence, noting the applicant's self-reports were inconsistent with her medical records, which showed improvement post-accident.

The application for catastrophic impairment, non-earner benefits, and other medical benefits was dismissed.

The applicant, a pedestrian struck by a motor vehicle, sought a catastrophic impairment designation under Criterion 4 of the Statutory Accident Benefits Schedule for a traumatic brain injury.

The applicant relied on a GOS-E rating of Severe Disability provided by the respondent's occupational therapist.

The Tribunal found that under section 45(2) of the Schedule, a GOS-E assessment must be conducted by a physician or neuropsychologist.

Because the applicant did not provide a qualifying medical opinion to support the occupational therapist's findings, and the respondent's neurologist found a 'good recovery', the applicant failed to meet his onus.

The application was dismissed.

The applicant sought statutory accident benefits after witnessing a fatal bus accident, claiming it caused a catastrophic impairment (schizophrenia).

The respondent denied the benefits, arguing the applicant's condition was pre-existing or prodromal.

The Tribunal found that while the accident may have triggered an acute psychotic episode, the applicant was likely prodromal for years prior and failed to prove he sustained a Class 4 marked or Class 5 extreme impairment in the required spheres of function.

The Tribunal also dismissed claims for attendant care, rehabilitation support worker services, and other expenses, as the applicant's non-catastrophic policy limits were exhausted and the expenses were either not incurred or not reasonable and necessary.

The applicant, a pedestrian struck by a vehicle, sought a determination that she sustained a catastrophic impairment due to psychological and emotional damage.

The Tribunal reviewed extensive medical and occupational therapy evidence, finding that the applicant's pre-accident active lifestyle had been replaced by severe avoidant behaviours, fatigue, and an inability to cope with stress.

Preferring the evidence of the applicant's psychiatric assessor over the respondent's, the Tribunal concluded the applicant suffered a marked impairment in the domain of adaptation.

The claims for interest and a special award were dismissed as there were no specific monetary benefits in dispute.

The applicant was catastrophically impaired in a motor vehicle accident and sought statutory accident benefits, including attendant care and home modifications.

The respondent insurer partially denied the claims based on its own assessments.

The Licence Appeal Tribunal found that the applicant's functional limitations, including cognitive and physical impairments, necessitated the maximum attendant care benefit of $6,000 per month and home modifications totaling $344,864, which included an in-home elevator and therapy room.

The Tribunal also awarded the cost of a housing analysis assessment but denied the cost of a second attendant care assessment submitted prematurely.

Finally, the Tribunal ordered a special award under s. 10 of Regulation 664, finding the respondent unreasonably withheld benefits by failing to properly investigate the applicant's functional needs despite having access to medical evidence supporting the claims.

The insurer appealed the Arbitrator's finding that the insured sustained a catastrophic impairment, arguing the Arbitrator applied the wrong causation test.

The insured cross-appealed the denial of Non-Earner Benefits, Housekeeping, and Attendant Care Benefits.

The Director's Delegate held that the 'but for' test, not the 'material contribution' test, is the correct causation test in accident benefits cases.

The Delegate found the Arbitrator misapprehended critical evidence regarding both the catastrophic impairment and Non-Earner Benefits claims, and remitted those issues for re-hearing.

The denial of Housekeeping and Attendant Care Benefits was upheld as the Arbitrator reasonably found the expenses were not incurred.