Kathleen Mertes

The respondent insurer requested a reconsideration of a Licence Appeal Tribunal decision that granted the applicant entitlement to a partially approved psychological treatment plan for observation and monitoring.

The insurer argued the Tribunal breached procedural fairness by admitting a late-served letter from a psychologist and erred in interpreting section 25 of the Statutory Accident Benefits Schedule regarding a $200 fee limit.

The Tribunal dismissed the reconsideration request, finding no error in its procedural fairness analysis under Rule 9.3 and confirming that the $200 limit applies to the review and approval of an OCF-18, not to the assessments proposed within it.

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

The Tribunal found the respondent's denial of a $2,198.80 physiotherapy treatment plan failed to comply with the notice requirements under s. 38(8) of the Schedule, entitling the applicant to payment for incurred services.

However, the denial of a $2,693.82 occupational therapy assessment was compliant, and the applicant failed to prove it was reasonable and necessary.

The Tribunal awarded interest on overdue benefits but declined to order a special award under s. 10 of Reg. 664, finding the benefits were not unreasonably withheld.

The applicant sought statutory accident benefits following a motor vehicle accident, disputing the insurer's denial of two physiotherapy treatment plans and a portion of a psychological treatment plan.

The Tribunal found the physiotherapy plans were not reasonable and necessary, preferring the evidence of the insurer's examination assessors over the applicant's medical reports, which contained inconsistencies regarding pre-existing conditions.

The Tribunal approved the disputed psychological treatment for observation and monitoring, finding it integral to the approved psychotherapy.

Claims for a special award and costs were dismissed, while interest was granted on the overdue psychological benefits.

The applicant sought entitlement to various statutory accident benefits following a motor vehicle accident, including treatment plans for a retroactive attendant care assessment, massage therapy, rehabilitation support worker services, optometric services, occupational therapy, and psychological services.

The Tribunal found the applicant was entitled to the $2,200.00 retroactive attendant care assessment because it covered a different post-accident period than the approved in-home assessment and was supported by medical evidence of functional limitations.

The remaining treatment plans were denied, largely because the applicant failed to establish they were reasonable and necessary, or because administrative costs exceeded the Professional Services Guideline limits.

The applicant's claim for an award under s. 10 of Regulation 664 was also dismissed.

The applicant sought payment for two treatment plans for chiropractic services and interest following a motor vehicle accident.

The respondent denied the benefits based on an independent medical examination which concluded the injuries had largely resolved.

The adjudicator found that the applicant failed to meet the burden of proving the treatment plans were reasonable and necessary, noting a lack of formal referrals for chiropractic treatment and an absence of progress reports demonstrating that treatment goals were being met.

The application was dismissed and no interest was awarded.

The applicant sought entitlement to statutory accident benefits following a 2019 motor vehicle accident, disputing the insurer's denial of various treatment and assessment plans.

The Licence Appeal Tribunal found that the applicant failed to prove that psychiatric, psychological, orthopaedic, and functional abilities assessments were reasonable and necessary.

However, the Tribunal partially approved a physiotherapy treatment plan, noting that pain reduction is a legitimate goal, while excluding the cost of orthotic devices unrelated to the accident.

The applicant's request for an award under s. 10 of O. Reg. 664 was denied, as the insurer's conduct was not found to be unreasonable.

The applicant sought entitlement to statutory accident benefits following a motor vehicle accident, specifically claiming costs for psychiatric, orthopaedic, functional abilities, and psychological assessments, as well as a physiotherapy treatment plan.

The Tribunal dismissed the claims for the assessments, finding the applicant failed to demonstrate they were reasonable and necessary, noting she had already been diagnosed and was receiving treatments.

The Tribunal partially granted the physiotherapy treatment plan, approving it for pain reduction but excluding the cost of orthotic devices unrelated to the accident.

The claim for a special award under s. 10 of Reg. 664 was dismissed, as the insurer's conduct was not found to be unreasonable.

Interest was awarded on the overdue physiotherapy benefits.

The applicant sought statutory accident benefits following a motor vehicle accident, disputing their placement in the Minor Injury Guideline and claiming entitlement to chronic pain and psychological assessments.

The matter proceeded to a written hearing.

The applicant failed to file any written submissions or evidence.

As the applicant bore the onus of proof, the Tribunal found they failed to demonstrate entitlement to removal from the MIG or to the disputed benefits.

The application was dismissed.

The applicant sought statutory accident benefits for psychological services and a doctor's visit following a motor vehicle accident.

The respondent insurer denied the benefits, arguing they were not reasonable and necessary and relying on an independent psychological assessment.

The Tribunal found that the applicant's treating practitioners provided sufficient corroborating medical evidence of ongoing psychological impairments, including depression and PTSD, to establish that the treatment plan and doctor's visit were reasonable and necessary.

The Tribunal ordered the respondent to pay the disputed benefits with interest, but declined to order a special award under s. 10 of Reg. 664, finding the insurer's conduct did not rise to the level of unreasonableness required.

The applicant sought entitlement to income replacement benefits (IRBs) and various medical and rehabilitation benefits following a motor vehicle accident.

The Tribunal found the applicant was entitled to pre-104-week IRBs due to psychological impairments, including driving anxiety, which caused a substantial inability to perform her pre-accident employment.

However, she was not entitled to post-104-week IRBs as she failed to prove a complete inability to engage in suitable employment.

The Tribunal also approved treatment plans for chiropractic and massage therapy but denied an orthopaedic assessment and an enhanced hourly rate for a psychotherapist providing psychological services.

The applicant requested a reconsideration of a Licence Appeal Tribunal decision that denied his claims for accident benefits, interest, and an award.

The applicant argued the Tribunal committed a material breach of procedural fairness and made errors of law, including improperly handling a motion to exclude evidence, misapplying the Personal Information Protection and Electronic Documents Act (PIPEDA), and failing to apply the test for causation.

The Adjudicator dismissed the request, finding no breach of procedural fairness and concluding that the applicant was attempting to re-litigate issues already decided.

The applicant sought statutory accident benefits for various treatment plans, including assistive devices, psychological services, a chronic pain assessment, and a neurology assessment, following a 2018 motor vehicle accident.

The respondent denied the plans.

The Tribunal found that the applicant failed to prove on a balance of probabilities that the proposed treatment plans were reasonable and necessary.

The Tribunal also found that the respondent complied with the notice requirements under section 38 of the Schedule.

The application was dismissed in its entirety, and claims for interest and a section 10 award were denied.

The applicant sought entitlement to statutory accident benefits following a motor vehicle accident, specifically claiming costs for physiotherapy, psychological services, and a multi-disciplinary catastrophic impairment assessment.

The Licence Appeal Tribunal dismissed the application, finding that the applicant failed to provide sufficient medical evidence or submissions to prove the treatment plans were reasonable and necessary.

The Tribunal preferred the respondent's psychological assessment, which concluded the applicant had reached maximum recovery, over the applicant's evidence.

Claims for interest and an award for unreasonable delay were also dismissed.

The applicant sought payment for three chiropractic treatment plans following a motor vehicle accident.

The respondent denied the benefits, arguing the treatments were not reasonable and necessary and pointing to the applicant's extensive pre-existing conditions, including fibromyalgia and chronic pain.

The Tribunal found that the applicant failed to meet his burden of proof, noting that the proposed treatment plans overlapped and duplicated services, reducing their reliability.

The Tribunal preferred the respondent's section 44 musculoskeletal assessment, which concluded the applicant had reached maximum medical improvement for soft-tissue injuries.

The application was dismissed, and no interest was awarded.

The applicant sought statutory accident benefits following a 2017 motor vehicle accident.

The Licence Appeal Tribunal dismissed the application in its entirety.

The Tribunal found the insurer correctly paid the psychotherapist rate rather than the psychologist rate for psychological services.

The claim for a chronic pain management program was dismissed because the treatment plan was submitted too late to be completed within the 5-year maximum entitlement period, and causation was not proven.

The claim for an orthopaedic mattress was barred by res judicata, as it had been denied in a prior Tribunal decision between the same parties.

Claims for an award and interest were also dismissed as no benefits were overdue.

The respondent insurer requested a reconsideration of a Tribunal decision that found the applicant entitled to a psychological assessment treatment plan, interest, and a special award under section 10 of Regulation 664.

The Vice-Chair dismissed the request regarding the treatment plan and interest, finding the Tribunal acted within its jurisdiction and any factual errors would not have changed the outcome.

However, the Vice-Chair granted the reconsideration regarding the special award, finding the Tribunal committed a material breach of procedural fairness by failing to provide reasons or specify the award percentage.

Upon varying the decision, the Vice-Chair found the insurer's conduct in handling duplicate treatment plans was not excessive or imprudent, and vacated the special award.

The applicant sought a determination of catastrophic impairment under Criterion 6 of the Statutory Accident Benefits Schedule following a motor vehicle accident.

The applicant relied on a revised assessment by an orthopedic surgeon, which incorporated a whole person impairment rating from a chiropractor.

The Tribunal found the chiropractor was not qualified to make a catastrophic impairment determination and gave little weight to the revised assessment.

Relying on the respondent's orthopedic assessment and surveillance evidence showing the applicant functioning without walking aids, the Tribunal concluded the applicant did not meet the 55% whole person impairment threshold.

The application was dismissed, and no award for unreasonable delay was granted.

The applicant sought statutory accident benefits following a motor vehicle accident, including non-earner benefits, attendant care benefits, and various medical and rehabilitation benefits.

The Licence Appeal Tribunal dismissed the application in its entirety.

The adjudicator found the applicant to be a poor historian whose self-reported limitations were inconsistent with contemporaneous medical records.

The tribunal preferred the evidence of the respondent's assessors, concluding that the applicant did not suffer a complete inability to carry on a normal life, did not incur attendant care expenses, and failed to prove the claimed medical benefits were reasonable and necessary.

The applicant sought various medical and rehabilitation benefits following a motor vehicle accident, including natural supplements, medical marijuana, Platelet Rich Plasma (PRP) therapy, physiotherapy, psychological services, and a visual assessment.

The Licence Appeal Tribunal dismissed the application in its entirety.

The Tribunal found that medical marijuana was contraindicated due to the applicant's pre-existing conditions, and that PRP therapy was experimental and thus excluded under s. 15(2)(a) of the Schedule.

Relying on independent medical examinations, the Tribunal concluded that the remaining physical and psychological treatment plans were not reasonable and necessary.

The applicant sought statutory accident benefits following a motor vehicle accident, disputing the respondent's denial of treatment plans for chiropractic services, a chronic pain assessment, and a psychological assessment.

The Tribunal found the applicant failed to prove the chiropractic and chronic pain treatment plans were reasonable and necessary, noting her failure to produce pre-accident and post-accident clinical notes from her family physician and the lack of objective evidence of impairment in the insurer's orthopaedic examination.

However, the Tribunal approved the psychological assessment, as the respondent conceded it was reasonable and necessary based on its own psychological examination.

The Tribunal also ordered the respondent to pay interest and a special award under section 10 of O. Reg. 664 solely in relation to the delayed payment for the psychological assessment.