Michal Baura

The applicant sought statutory accident benefits following a motor vehicle accident, including a non-earner benefit and several treatment plans for psychological, concussion, and chiropractic services, as well as cognitive and orthopaedic assessments.

The Tribunal found the applicant did not meet the test for a complete inability to carry on a normal life, denying the non-earner benefit.

The Tribunal partially approved the psychological treatment plan for 1.5-hour sessions but denied the costs for counselling notes and a progress report.

All other treatment plans and assessments were denied as the applicant failed to prove they were reasonable and necessary.

The applicant sought statutory accident benefits following a motor vehicle accident, including a non-earner benefit, funding for a functional cognitive assessment, and psychological services.

The Tribunal dismissed the application.

Applying the Heath test, the adjudicator found the applicant did not suffer a complete inability to carry on a normal life, as medical evidence showed she remained independent in self-care and could perform light housekeeping, with her knee pain likely stemming from pre-existing arthritis.

The treatment plans were deemed not reasonable and necessary based on respondent medical examinations indicating her neurological and psychological issues had largely resolved or did not require the proposed assessments.

A claim for an award under s. 10 of Regulation 664 was also dismissed as the insurer's denials were reasonably based on medical evidence.

The applicant sought entitlement to statutory accident benefits for psychological services and a chronic pain assessment following a motor vehicle accident.

The applicant argued the respondent failed to comply with the notice requirements under s. 38(8) of the Schedule when denying the treatment plans.

The Tribunal found the respondent's denial letters and notices of examination contained sufficient medical reasons and complied with the Schedule.

As the applicant made no submissions on the substantive reasonableness and necessity of the treatment plans, the claims were dismissed, along with claims for interest and an award.

The applicant was involved in a motor vehicle accident and sought statutory accident benefits.

The respondent denied several treatment plans, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found that the applicant sustained a psychological injury, removing her from the MIG, and approved treatment plans for a psychological assessment and psychological treatments.

However, the Tribunal denied the treatment plans for chiropractic treatments and a chronic pain assessment, finding insufficient medical evidence to prove they were reasonable and necessary.

The applicant was awarded interest on overdue payments but denied an award under O. Reg. 664, as the respondent's reliance on its assessors was not unreasonable.

The applicant sought statutory accident benefits following a motor vehicle accident, including non-earner benefits, medical benefits, and costs of examinations.

The respondent denied the benefits.

The Tribunal found that the applicant failed to prove on a balance of probabilities that she suffered a complete inability to carry on a normal life, noting her pre-existing conditions and failure to identify pre-accident activities in accordance with the Heath test.

The Tribunal also found that the applicant did not meet her burden to demonstrate that the disputed treatment and assessment plans were reasonable and necessary, relying on insurer's examinations that found no ongoing impairment.

The application was dismissed.

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

The respondent denied certain treatment plans on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG).

The applicant argued she should be removed from the MIG due to chronic pain, pre-existing conditions, and psychological impairment.

The Tribunal found that the applicant failed to establish chronic pain syndrome, as she did not meet the AMA Guides criteria and her functionality was not significantly impaired.

The Tribunal also found insufficient evidence of a psychological impairment or that her pre-existing conditions prevented maximal recovery.

The applicant's injuries were deemed predominantly minor, and she was entitled to the disputed treatment plans only up to the remaining MIG limit.

The claim for a special award was dismissed.

The appellant appealed two decisions of the Licence Appeal Tribunal regarding statutory accident benefits.

In the first appeal, the appellant argued that an adjudicator reconsidering their own decision violated procedural fairness.

In the second appeal, the appellant argued that the Tribunal's withdrawal of a decision mistakenly rendered by an adjudicator who did not hear the oral evidence created a reasonable apprehension of bias.

The Divisional Court dismissed both appeals, finding that the Tribunal's reconsideration process is procedurally fair and that correcting an administrative error by withdrawing the mistaken decision and having the correct adjudicator issue a new one cured any procedural defect without raising a reasonable apprehension of bias.

The applicant insurer sought repayment of income replacement benefits paid to the respondent after he had returned to work.

The respondent had entered into a settlement agreement to repay the funds but failed to make consistent payments.

The Tribunal found that the respondent committed wilful misrepresentation by failing to advise the insurer of his return to work while continuing to receive benefits.

The Tribunal ordered the respondent to repay the outstanding balance of $4,528.56, plus interest.

The applicant sought statutory accident benefits for physiotherapy and chiropractic treatment following a 2015 motor vehicle accident.

The respondent denied the treatment plans.

The Licence Appeal Tribunal found that the applicant failed to prove the May 8, 2018 treatment plan was reasonable and necessary due to a lack of compelling contemporaneous medical evidence.

However, the Tribunal awarded $800 for eight sessions of physiotherapy under the January 17, 2019 treatment plan, as it was supported by recommendations from the applicant's family physician and a chronic pain clinic.

The remainder of the 2019 treatment plan was denied.

The applicant requested a reconsideration of a decision finding that his injuries from a motor vehicle accident fell within the Minor Injury Guideline (MIG) and denying entitlement to a chronic pain assessment.

The applicant argued the adjudicator breached procedural fairness, exceeded her jurisdiction, and made errors of law and fact, including by applying the AMA Guides to assess chronic pain.

The Licence Appeal Tribunal dismissed the request, finding no procedural unfairness in the adjudicator's consideration of the evidence or handling of submissions.

The Tribunal further held that the adjudicator did not err in using the AMA Guides criteria as factors to determine whether the applicant's chronic pain was severe enough to remove him from the MIG, nor did she err in her weighing of the medical evidence.

The insurer sought reconsideration of a decision ordering it to pay a $1,500 special award on two files for unreasonably withholding or delaying payment of attendant care benefits.

The insurer argued that the previous reconsideration decision did not explicitly order payment and that it was simply following the Tribunal's procedure to determine the final quantum.

The Vice-Chair dismissed the request, finding that the previous decision had settled a minimum amount due, which the insurer accepted and failed to pay for 10 months.

The Tribunal held that in the context of consumer protection legislation, it was unreasonable for the insurer to delay paying the undisputed minimum amount while litigating a minor remaining difference.

The applicant sought payment for a psychological assessment following a motor vehicle accident.

The insurer denied the treatment plan and mailed an Explanation of Benefits (EOB) on November 4, 2016.

The applicant filed an application with the Licence Appeal Tribunal on February 27, 2019, more than two years after the denial.

The Tribunal found that the applicant was deemed to have received the EOB by mail on November 14, 2016, triggering the two-year limitation period under section 56 of the Statutory Accident Benefits Schedule.

As the application was filed beyond the limitation period, the appeal was statute-barred and dismissed.

The applicant requested a reconsideration of a Tribunal decision that barred him from applying for income replacement benefits due to his failure to attend an insurer's examination.

The Vice-Chair found that the Tribunal made a significant error of law by concluding that the insurer's notice of the orthopaedic assessment complied with s. 44(5)(c) of the Schedule.

The notice failed to state the regulated health profession of the assessor.

As the notice was non-compliant, the insurer could not rely on s. 55(1)2 to bar the application.

The reconsideration was granted, and the withheld income replacement benefits were ordered payable, though a claim for a special award was denied.

The applicant was injured in a motor vehicle accident and sought medical, rehabilitation, and non-earner benefits.

The respondent insurer denied the claims on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG).

The applicant argued that chronic pain and psychological impairments took him outside the MIG.

The Tribunal found that the applicant did not meet the AMA Guides criteria for chronic pain and failed to prove a psychological impairment, giving little weight to the applicant's medical experts due to inconsistencies.

The Tribunal concluded the injuries were predominantly minor, dismissed the claim for non-earner benefits as the applicant returned to work and most pre-accident activities, and denied claims for a special award, interest, and costs.

The insurer sought reconsideration of a Tribunal decision awarding the insured attendant care benefits.

The insurer argued that the Tribunal erred in law by awarding benefits at a flat rate of $25 per hour rather than applying the mandatory maximum hourly rates set out in the Attendant Care Hourly Rate Guideline and the Form 1 Assessment of Attendant Care Needs.

The Vice-Chair agreed, finding that the Guideline rates are mandatory for services actually rendered and cannot be used merely as a calculation tool to establish a total monthly cap.

The reconsideration was granted in part, and the matter was remanded to the original adjudicator for a hearing limited to determining the proper quantum of the benefit based on the hours previously found to have been incurred.

The insurer sought reconsideration of a Tribunal decision awarding the insured attendant care benefits at a flat rate of $25 per hour.

The insurer argued that the adjudicator made a significant error of law by failing to apply the mandatory maximum hourly rates set out in the Attendant Care Hourly Rate Guideline and the Form 1 Assessment of Attendant Care Needs.

The Vice-Chair agreed, finding that the Guideline rates are mandatory for services actually rendered and cannot be used merely as a calculation tool to establish a total monthly cap.

The reconsideration was granted in part, and the matter was remanded to the original adjudicator to determine the proper quantum of benefits based on the hours previously found to have been incurred, applying the correct Guideline rates.

The applicant sought income replacement benefits following a motor vehicle accident.

The insurer argued the applicant was barred from proceeding because he failed to attend three requested medical and vocational examinations.

The Tribunal found the insurer provided sufficient notice for the orthopaedic assessment but not for the functional abilities or job site evaluations.

Consequently, the applicant is barred from proceeding with his claim until he attends the orthopaedic assessment.

The Tribunal also awarded the applicant 25 per cent of a delayed benefit payment under Regulation 664, but denied his request for costs.

The applicant sought a medical and rehabilitation benefit of $12,001.80 for a chronic pain treatment program following a motor vehicle accident.

The insurer denied the claim.

The Tribunal found that the applicant did not meet the AMA criteria for chronic pain, noting that he had returned to full-time work, completed a university degree, and maintained social and self-care activities.

The Tribunal concluded the treatment was not reasonable and necessary, dismissing the appeal and the claims for interest and a special award.

The applicant sought payment for orthopaedic and psychological assessments following a motor vehicle accident.

The respondent denied the assessments, and the applicant argued the denial was untimely under section 38(8) of the Statutory Accident Benefits Schedule.

The Tribunal found that while the denial was late, the applicant had not incurred the costs prior to receiving notice of the denial.

The Tribunal held that the applicant was barred from adjudicating the psychological assessment due to a failure to attend a properly scheduled section 44 insurer's examination.

Furthermore, the orthopaedic assessment was found not to be reasonable and necessary.

Claims for a special award under Regulation 664, interest, and costs were all dismissed.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for chiropractic and massage treatment.

The insurer denied the treatment plan, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) and that she had reached maximum recovery.

The arbitrator found that the applicant suffered from chronic pain syndrome exacerbated by pre-existing arthritis and osteoporosis, placing her injuries outside the MIG.

The arbitrator preferred the evidence of the applicant's family physician over the insurer's orthopaedic assessor, finding the treatment plan reasonable and necessary.

The insurer was ordered to pay the disputed medical benefits with interest.