Kevin Griffiths

The applicant sought statutory accident benefits following a motor vehicle accident, including an in-home assessment and three neuropsychological assessments.

The respondent insurer raised preliminary issues arguing the claims were statute-barred.

The adjudicator found the claim for the in-home assessment was barred under s. 38(2) of the Schedule because the expense was incurred before the treatment plan was submitted.

The adjudicator also found the claim for the neuropsychological assessments was barred under s. 56 of the Schedule because the application was filed outside the two-year limitation period.

The adjudicator declined to extend the limitation period under s. 7 of the Licence Appeal Tribunal Act, 1999, noting the applicant had previously withdrawn a timely application without explanation.

The application was dismissed.

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

The insurer raised a preliminary issue, arguing the applicant was barred from proceeding under s. 55(1)2 of the Schedule for failing to attend multiple scheduled insurer's examinations (IEs) under s. 44.

The Tribunal found the applicant failed to attend the IEs for income replacement benefits (IRBs) without a reasonable explanation, and declined to grant relief under s. 55(2), dismissing the IRB claim.

However, the Tribunal allowed the claims for chiropractic services, a functional abilities evaluation, and a psychological assessment to proceed, finding the insurer either failed to schedule an IE for the specific benefit or provided notices that lacked sufficient medical reasons.

The applicant requested a reconsideration of a preliminary decision that suspended his right to dispute entitlement to attendant care and home modification benefits due to his failure to attend section 44 insurer examinations.

The applicant argued that his mental and physical impairments prevented him from attending non-therapeutic assessments and that the Tribunal failed to consider the Ontario Human Rights Code, section 55 of the Schedule, and the totality of his medical evidence.

The Vice Chair dismissed the request, finding that the Tribunal had properly considered the lack of medical evidence supporting accommodation, correctly balanced procedural fairness, and made no errors of law or fact.

The applicant was injured in a motor vehicle accident in Michigan and sought statutory accident benefits from her Ontario insurer.

In a preliminary issues hearing, the Tribunal determined that the Ontario Schedule, not the Michigan Code, applied to the claim because the insurer had not filed a certificate in Michigan.

The Tribunal also held that an OCF-19 must be submitted for a catastrophic impairment determination, rejecting the argument that an insured could be 'deemed' catastrophically impaired.

Finally, the Tribunal found several of the applicant's claims for benefits were statute-barred by the two-year limitation period or precluded because valid applications (OCF forms) were never submitted to the insurer, though it exercised its discretion to extend the limitation period for a few specific claims.

The appellant appealed two arbitration orders denying her claims for non-earner benefits, medical benefits, and a special award, and ordering her to pay HST on the insurer's disbursements.

The Director's Delegate dismissed the appeal, finding no errors of law.

The Arbitrator correctly applied the test for non-earner benefits, properly concluded medical benefits were not incurred, and correctly applied the legislative requirement that treatment plans be signed.

The Delegate also refused to admit a new invoice as fresh evidence because it could have been adduced at the arbitration hearing.

Finally, the Delegate upheld the order requiring the appellant to pay HST on expert witness disbursements.

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

The respondent requested further independent examinations (IEs) under s. 44 of the Statutory Accident Benefits Schedule to address attendant care and home modifications.

The applicant refused to attend, citing mental and physical health issues, and argued the respondent should rely on paper reviews of his experts' reports.

The Tribunal held that procedural fairness requires the respondent to have the opportunity to challenge the applicant's medical evidence with its own assessors.

The Tribunal suspended the applicant's right to proceed with all issues, except housekeeping expenses, until he attends the requested IEs.

The respondent insurer requested a reconsideration of a decision finding the applicant sustained a catastrophic impairment and was entitled to attendant care benefits (ACBs) for services provided by his spouse.

The insurer argued the adjudicator erred by admitting opinion evidence on causation from a treating chiropractor who was not qualified as an expert, and by awarding ACBs for care provided by a family member.

The Associate Chair denied the reconsideration, holding that the chiropractor's evidence was admissible as a 'participant expert' under Westerhof, and that the spouse, a trained personal support worker and registered practical nurse, provided the attendant care services in the course of her profession.

The adjudicator's findings that the applicant promised to pay his spouse and required overnight supervision were reasonable and did not constitute significant errors of law or fact.

The insurer requested a reconsideration of a Licence Appeal Tribunal decision that awarded the insured physiotherapy services, orthopaedic and psychiatric assessments, and a special award under s. 10 of Regulation 664.

The Executive Chair found no significant error of law in the adjudicator's determination that the treatment plans and assessments were reasonable and necessary for managing the insured's chronic pain.

However, the Executive Chair allowed the reconsideration regarding the s. 10 award, finding that the adjudicator erred by conflating the reasonableness of the treatment plans with the unreasonableness of the insurer's conduct.

The award was overturned as there was no evidence the insurer unreasonably withheld or delayed payments.

The applicant was injured in a motor vehicle accident and sought a determination of catastrophic impairment, along with attendant care benefits and various medical and rehabilitation benefits.

The Tribunal found that the applicant sustained a catastrophic impairment, preferring the evidence of the applicant's expert who assigned a 64% physical impairment rating over the respondent's expert.

The Tribunal awarded attendant care benefits of $3,704.91 per month from the date the assessment forms were submitted, but denied retroactive benefits.

The Tribunal also awarded case management services but denied other disputed treatment plans due to late submission or lack of evidence.

The applicant sought a non-earner benefit following a 2013 motor vehicle accident, claiming it exacerbated her pre-existing psychiatric issues and chronic pain.

The insurer denied the benefit, arguing her activities of daily living had not substantially changed.

The arbitrator found that the applicant's normal life had changed due to a prior 2011 accident and family conflicts, not the 2013 accident.

Despite an aggravation of her chronic pain, she continued to engage in substantially all her pre-accident activities, such as attending workshops, driving, and socializing.

The application was dismissed, and expenses were awarded to the insurer.

The applicant sought statutory accident benefits for physiotherapy services and orthopaedic and psychiatric assessments following a motor vehicle accident.

The respondent insurer denied the claims based on insurer examinations.

The adjudicator found that the physiotherapy services were reasonable and necessary for managing the applicant's chronic pain, rejecting the insurer's argument that treatment must lead to full recovery.

The adjudicator also approved the assessments, noting the insurer's assessors conducted paper reviews without reviewing key medical reports.

Finding that the insurer unreasonably withheld payments, the adjudicator ordered a special award of 50% of the disputed amounts, plus interest.

The applicant was injured in a motor vehicle accident and claimed statutory accident benefits.

A dispute arose and the applicant applied for mediation.

The parties agreed to extend the mediation date beyond the 60-day statutory limit but failed to comply with the mandatory procedural steps under Rule 19.3 of the Dispute Resolution Practice Code.

The applicant filed for arbitration before the scheduled mediation date.

The arbitrator held that because the parties did not comply with the mandatory procedural steps to extend the mediation timeline, the agreement to extend was invalid.

Consequently, mediation was deemed to have failed at the expiry of the 60-day limit, which occurred before the arbitration application was filed.

The applicant was therefore entitled to commence the arbitration proceeding.

Following a preliminary issue hearing where it was determined that no motor vehicle accident had occurred, the insurer sought repayment of accident benefits paid to the applicants and its expenses for the arbitration.

The applicants did not participate in the written expense hearing.

The arbitrator ordered the applicants to repay the benefits they received, finding the claims were made under a misrepresentation.

The arbitrator also ordered the applicants to pay the insurer's reasonable expenses for the arbitration, reducing the claimed amount of $24,973.36 to $9,242.96 after finding the claimed legal fees and disbursements were excessive.

The applicant sought accident benefits following a motor vehicle accident.

After his representative was removed from the record, the applicant failed to attend multiple pre-hearings and the preliminary issue hearing, despite receiving proper notice.

The arbitrator proceeded in the applicant's absence and dismissed the application for arbitration due to the applicant's failure to provide evidence in support of his claims.

The insurer was awarded $3,102.00 in legal expenses and disbursements.

The applicants sought accident benefits following an alleged motor vehicle collision.

The insurer denied the claims, alleging the accident was staged and the applicants made material misrepresentations.

At a preliminary issue hearing, the arbitrator heard evidence from the applicants, the occupants of the other vehicle (who confessed to participating in a staged accident scheme), and accident reconstruction experts.

The arbitrator found the applicants' version of events highly improbable, noting inconsistencies between their testimony and the physical damage to the vehicles, the lack of independent witnesses, and the improbable behaviour of the passengers.

The arbitrator concluded the reported accident did not occur and dismissed the claims.

The respondent's son was struck by a car.

The respondent, who was sleeping, was awoken by another son and told of the incident.

While rushing down the stairs to help, the respondent fell and injured himself.

He claimed statutory accident benefits.

The arbitrator found he was involved in an 'accident' under s. 2(1) of the SABS.

On appeal, the Director's Delegate reversed the decision, finding that the respondent did not see, hear, or feel the impact, and his knowledge was mediated through his son.

This constituted an intervening act that broke the chain of direct causation.

The appeal was allowed.

The applicant sought statutory accident benefits after falling from his bicycle and sustaining a severe head injury.

The insurer disputed that the injuries were caused by the use or operation of an automobile.

At a preliminary issue hearing, the arbitrator heard uncontested expert evidence from a collision reconstructionist that the damage to the bicycle's front wheel could only have been caused by a motor vehicle running over it.

The arbitrator concluded on a balance of probabilities that the applicant was struck by an unidentified automobile, satisfying the definition of an accident under the Schedule.

The applicants applied for statutory accident benefits following a motor vehicle accident.

The insurer sought repayment, asserting the applicants were not involved in an accident as defined in the Schedule.

The applicants applied for arbitration but failed to attend the scheduled hearing or maintain contact with their counsel, who was permitted to withdraw from the record.

The arbitrator dismissed the applications for arbitration due to abandonment and ordered the applicants to pay the insurer's expenses.

The applicant applied for statutory accident benefits following an alleged motor vehicle accident, which the insurer denied on the basis that the accident was staged.

The applicant's representative brought a motion to withdraw due to a breakdown in the solicitor-client relationship.

The applicant failed to attend the arbitration hearing despite being properly served.

The arbitrator granted the representative's motion to withdraw and proceeded with the hearing in the applicant's absence.

As the applicant presented no evidence, the application for arbitration was dismissed, and the applicant was ordered to pay the insurer's expenses of $948.31.

The applicant applied for statutory accident benefits following an alleged motor vehicle accident, which the insurer denied on the basis that the accident was staged.

The applicant's representative brought a motion to withdraw due to a breakdown in the solicitor-client relationship.

The applicant failed to attend the arbitration hearing.

The arbitrator granted the representative's motion to withdraw, dismissed the application for arbitration due to the applicant's failure to attend and present evidence, and ordered the applicant to pay the insurer's arbitration expenses.