Humberto Geovo

The applicant was injured in a motor vehicle accident and sought funding for a chronic pain treatment program.

The respondent insurer partially approved the plan for psychological treatment but denied the physical therapy and chronic pain components, relying on an insurer's examination.

The Licence Appeal Tribunal found the applicant credible and preferred the evidence of his treating assessors, who diagnosed chronic pain syndrome caused by the accident.

The Tribunal ordered the insurer to pay the remaining cost of the treatment plan, excluding transportation expenses, plus interest on overdue payments.

The applicant was injured in a motor vehicle accident and sought payment for an orthopaedic assessment.

The insurer denied the claim, arguing the assessment should be funded through OHIP and that the applicant fell within the Minor Injury Guideline.

The Tribunal found that the insurer failed to provide valid medical reasons for the denial within the required timeframe under s. 38(8) of the Schedule, triggering automatic payment under s. 38(11).

The Tribunal also rejected the insurer's broad interpretation of s. 47(2) regarding OHIP coverage.

The applicant was awarded the cost of the assessment and interest, but denied costs.

The insurer sought expenses following its success in a preliminary issue hearing where it was determined that the insured was precluded from proceeding with her arbitration due to a full and final settlement.

The arbitrator considered the criteria under Rule 75.2 of the Dispute Resolution Practice Code.

While the insurer was entirely successful, the insured's position was not manifestly unfounded and raised a legitimate issue regarding the cooling-off period.

The arbitrator awarded the insurer $1,500 in expenses.