Nathalie V. Rosenthall

The applicant requested a reconsideration of a decision finding the respondent was not liable to pay an income replacement benefit due to a material misrepresentation.

The applicant argued the Tribunal exceeded its jurisdiction, denied procedural fairness, failed to apply strict statutory interpretation, and erred in declining to apply equitable principles of waiver and estoppel.

The Tribunal dismissed the request, finding no breach of procedural fairness, no ambiguity requiring strict statutory interpretation, and confirming that the Tribunal lacks jurisdiction to apply equitable remedies under the Statutory Accident Benefits Schedule.

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

The respondent determined the applicant's injuries fell within the Minor Injury Guideline (MIG) and denied income replacement benefits (IRB) and certain treatment plans.

The Tribunal found that the applicant's injuries were predominantly minor and that he failed to prove a pre-existing condition, psychological injury, or chronic pain that would remove him from the MIG.

The Tribunal also found the applicant was not entitled to an IRB as he did not suffer a substantial inability to perform the essential tasks of his pre-accident employment.

However, the Tribunal found the disputed physiotherapy treatment plans were reasonable and necessary, and ordered them payable up to the $3,500 MIG limit, less amounts already paid.

The applicant, who sustained a catastrophic brain injury in a motorcycle accident, sought $7,017.40 for the unapproved portion of a home modification assessment treatment plan.

The insurer had partially approved the plan up to the $2,000 cap for assessments.

The Tribunal found that the home modification assessment involved an appraisal of the applicant's health status and functional limitations, and was therefore subject to the $2,000 cap under s. 25(5)(a) of the Schedule.

The application for the unapproved balance and interest was dismissed.

The applicant was injured in a motor vehicle accident and sought income replacement benefits, which were denied by the respondent.

The respondent raised a preliminary issue that the applicant was barred from proceeding with her Licence Appeal Tribunal application due to her failure to attend insurer examinations under section 44 of the Schedule and her failure to provide requested information under section 33.

The Tribunal found that the applicant was not barred from proceeding due to the section 33 non-compliance, as the Schedule does not preclude an application on that basis.

However, the Tribunal held that the applicant was barred under section 55(1) from disputing the denial of the post-104 weeks income replacement benefit until she attends the reasonably necessary insurer examinations.

The applicant insurer sought reconsideration of a Tribunal decision that dismissed its application for repayment of Income Replacement Benefits.

The Tribunal had dismissed the application because the insurer failed to include a copy of the notice of repayment in its hearing submissions, despite referencing it in its application and case conference materials.

The Executive Chair granted the reconsideration, finding that the Tribunal breached procedural fairness by dismissing the application on an uncontested issue without providing the insurer an opportunity to address the missing document.

A rehearing was ordered.

The applicant insurer sought repayment of income replacement benefits and accountant fees from the respondent, alleging wilful misrepresentation.

The respondent did not participate in the hearing.

The Tribunal dismissed the application, finding that the applicant failed to provide evidence that it had given the respondent notice of the repayment amount, which is a mandatory requirement under section 52 of the Statutory Accident Benefits Schedule.

A statutory third party insurer sought leave to bring a motion after the action had been set down for trial in order to compel the plaintiff to attend a psychiatric defence medical examination.

The insurer argued that it had only recently become aware of the psychiatric component of the claim and that, as a statutory third party with separate interests from the defendant insurer, it was entitled to its own medical examination.

The court held that there had been no unexpected or substantial change in circumstances justifying leave after the matter was set down for trial.

The court also found that the insurer’s interests were effectively the same as the defendant insurer’s and that a psychiatric defence examination had already been obtained.

The motion was therefore dismissed.

The respondent was injured in a motor vehicle accident and applied to the appellant for statutory accident benefits.

An arbitrator found the appellant was the first insurer to receive the application and ordered it to pay benefits pending the resolution of a priority dispute, despite the appellant's claim that it was a victim of a fraudulent pink slip and had no real nexus to the respondent.

The appellant appealed and sought a stay of the arbitrator's order pending the appeal.

The Director's Delegate denied the stay request, finding that granting a stay would thwart the clear legislative intent of O. Reg. 283/95, which is to ensure that the payment of accident benefits to claimants is not delayed due to disputes between insurers over who is liable to pay.