Michelle Friedman

The applicant, who sustained a catastrophic impairment in a motor vehicle accident, sought $14,900 for housekeeping and home maintenance expenses incurred prior to the catastrophic impairment determination.

The services were provided by her adult son.

The Tribunal found that the expenses were not 'incurred' under section 3(7)(e)(iii) of the Schedule because the son did not provide the services in the course of his ordinary employment or sustain an economic loss.

The Tribunal also declined to deem the expenses incurred under section 3(8), finding that the insurer did not unreasonably withhold or delay payment.

The application was dismissed.

The applicant sought a determination of catastrophic impairment following a motor vehicle accident.

The insurer raised a preliminary issue, arguing the applicant was precluded from proceeding under s. 55(1) of the Schedule because insurer examination reports had not yet been completed.

The adjudicator found no evidence that the applicant failed to attend the scheduled examinations or provide requested documentation.

The adjudicator held that waiting for the completion of reports prior to applying to the Tribunal would prejudice the applicant, and the application was not precluded.

The applicant was injured in a motor vehicle accident and sought funding for a catastrophic impairment assessment.

The respondent initially denied the $12,400.00 assessment on the basis that the applicant had exhausted the non-catastrophic funding limit, but later approved $10,400.00.

The applicant sought the $2,000.00 balance, which was for a clinic file review, as well as an award for unreasonable delay.

The Tribunal dismissed the claim for the balance, finding that file review is captured within the $2,000.00 per-assessment limit under section 25(5)(a) of the Schedule.

However, the Tribunal granted an award of $2,080.00 under section 10 of O. Reg. 664, finding that the respondent's initial denial unreasonably disregarded established caselaw.

The insurer sought reconsideration of a Tribunal decision awarding the insured a lump sum under O. Reg. 664 for unreasonably withholding or delaying income replacement benefits.

The insurer had erroneously deducted employment insurance from the benefits but later corrected the error and paid the outstanding balance.

The Vice-Chair found that the original adjudicator made a significant error of fact by concluding the insurer had conceded the error in a September 2016 letter.

The Vice-Chair held that the insurer's misinterpretation of the Schedule did not amount to unreasonable conduct warranting a lump sum award.

The reconsideration was allowed and the lump sum award was dismissed.

The applicant, a pedestrian who sustained catastrophic injuries in a motor vehicle accident and subsequently passed away, sought various medical and rehabilitation benefits.

The Licence Appeal Tribunal dismissed the claims, finding that several treatment plans were either already paid, not proven to be reasonable and necessary, or barred because the applicant failed to attend required insurer's examinations under section 44 of the Schedule.

The respondent's request for costs was also dismissed.

The applicant sought reconsideration of a Licence Appeal Tribunal decision that denied her claim for ongoing attendant care benefits.

The applicant argued that the Tribunal erred in finding it lacked equitable jurisdiction to apply estoppel by convention, which would have prevented the insurer from terminating benefits it had mistakenly paid for several months.

The Executive Chair dismissed the request, holding that the Tribunal must resolve disputes in accordance with the Statutory Accident Benefits Schedule and cannot use equity to override the statutory requirement that expenses be 'incurred.' Furthermore, the test for estoppel by convention was not met, as the parties did not share a mutual assumption and the applicant suffered no detriment.

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

After the applicant failed to attend two case conferences, the respondent requested that the application be dismissed as abandoned.

The Tribunal initially found that the application had been withdrawn by the applicant's paralegal at the first case conference.

The respondent requested a reconsideration, arguing that the application should be dismissed as abandoned and that the Tribunal breached procedural fairness by accepting late submissions from the applicant that were not served on the respondent.

The Executive Chair denied the request for reconsideration, finding that while a breach of procedural fairness occurred, it was inconsequential and caused no prejudice.

The Executive Chair upheld the finding that the application was withdrawn rather than abandoned, and denied the respondent's request for costs.

The insurer requested a reconsideration of two Licence Appeal Tribunal decisions which found that its notices denying treatment plans were defective under ss. 38(8) and (9) of the Statutory Accident Benefits Schedule.

The Tribunal had concluded that the defective notices triggered the mandatory consequences of s. 38(11), prohibiting the insurer from ever taking the position that the applicants' impairments fell within the Minor Injury Guideline (MIG) and requiring the insurer to pay for the treatment plans.

On reconsideration, the Executive Chair upheld the Tribunal's interpretation that the MIG prohibition applies to the entire claim and that s. 38(11)2 requires payment without a "reasonable and necessary" analysis.

However, the Executive Chair found an error regarding the quantum awarded to one applicant, as the insurer had subsequently provided a compliant notice that limited its obligation to pay.

The reconsideration was granted in part to reduce the quantum for that applicant, and otherwise denied.

The respondent insurer requested a reconsideration of a Licence Appeal Tribunal decision that granted the applicant entitlement to a chronic pain assessment.

The insurer argued that the Tribunal erred in law by applying a standard of proof based on a 'balance of possibilities' rather than a 'balance of probabilities.' The Executive Chair agreed, finding that the Tribunal explicitly applied the wrong standard of proof when assessing whether the assessment was reasonable and necessary.

The reconsideration request was granted, and the matter was remitted to the same Tribunal member for redetermination using the correct balance of probabilities standard.

The applicant's request for costs was denied.

The respondent insurer requested a reconsideration of a Licence Appeal Tribunal decision that awarded the applicant interest on an overdue payment for psychological services at a rate of 2 per cent per month.

The Executive Chair granted the reconsideration, finding that the Tribunal erred in law by applying the interest rate from a previous version of the Statutory Accident Benefits Schedule.

The decision was varied to apply the correct interest rates under section 51 of the current Schedule, which provides for 1 per cent per month before an application is commenced, and the Courts of Justice Act prejudgment interest rate thereafter.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for caregiving, housekeeping, attendant care, and medical expenses, as well as a special award.

The arbitrator found that the applicant failed to establish on a balance of probabilities that she suffered a substantial inability to perform her pre-accident caregiving and housekeeping tasks, or that she required the claimed attendant care assistance.

The arbitrator noted inconsistencies in the applicant's evidence, her failure to disclose her ongoing receipt of ODSP benefits to medical assessors, and preferred the evidence of the insurer's occupational therapist who found the applicant could perform her activities of daily living with assistive devices.

All claims for benefits, interest, and a special award were dismissed.

The applicant filed a human rights application alleging discrimination in the denial of health benefits.

The application was previously deferred pending the outcome of related union grievances.

After nearly three years with the grievance arbitration held in abeyance and no clear timeline for its resolution, the applicant requested to reactivate the application.

The Tribunal granted the request, finding that the lengthy delay and uncertain status of the arbitration meant that the conditions for deferral had not materialized, and reactivation was the most fair, just, and expeditious approach.