Adam Romain

The applicant, a 94-year-old pedestrian, was struck by a motor vehicle and subsequently sought statutory accident benefits.

He passed away approximately eight months after the accident, and his estate continued the application.

The Licence Appeal Tribunal held that the estate was not entitled to death benefits, as such benefits attach to dependents, nor funeral benefits, as the applicant failed to prove the accident was the direct cause of his death from C. Difficile.

The Tribunal also denied attendant care benefits incurred prior to the submission of a Form 1, and lodging expenses for lack of evidence.

The applicant was awarded partial reimbursement for a wheelchair rental and a transfer pole.

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 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.