Samia Alam

The applicant sought a determination of catastrophic impairment and entitlement to attendant care benefits and hearing aids following a motor vehicle accident.

The Licence Appeal Tribunal found that the applicant was statute-barred from claiming attendant care benefits because she failed to dispute the insurer's denial within the two-year limitation period, and the justice of the case did not warrant an extension.

On the issue of catastrophic impairment, the Tribunal applied the AMA Guides to assess the applicant's physical and psychological impairments, ultimately finding a combined Whole Person Impairment (WPI) of 56%, which exceeds the 55% threshold under Criterion 7.

The Tribunal denied the claim for hearing aids because the applicant incurred the expense without first submitting a treatment plan, contrary to section 38(2) of the Schedule.

The claim for a special award was also dismissed as the insurer did not unreasonably withhold or delay benefits.

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

The Licence Appeal Tribunal found that the applicant's injuries were predominantly minor and subject to the Minor Injury Guideline (MIG) limit, as she failed to establish that pre-existing conditions, chronic pain, or psychological impairments warranted removal.

The Tribunal also dismissed the applicant's claim for an income replacement benefit (IRB), finding she did not prove a substantial inability to perform the essential tasks of her employment during the pre-104-week period.

Claims for a treatment plan, an award, and costs were also dismissed.

The applicant sought statutory accident benefits after allegedly being struck by an e-bike.

The respondent denied benefits on the basis that the incident did not meet the definition of an 'accident' under the Statutory Accident Benefits Schedule.

The Tribunal found that the applicant failed to establish on a balance of probabilities that the e-bike was an 'automobile' in ordinary parlance or under any relevant statute, such as the Highway Traffic Act.

Consequently, the applicant was not involved in an 'accident' and the application for benefits was dismissed.

The applicant requested a reconsideration of a Licence Appeal Tribunal decision denying her entitlement to an income replacement benefit (IRB).

The applicant argued that the adjudicator erred in law by finding that her on-call work arrangement at a pasta factory did not constitute employment at the time of the accident under s. 5(1)(1)(i) of the Statutory Accident Benefits Schedule.

The adjudicator dismissed the request, affirming the application of the Divisional Court's test in Arab, which requires an exchange of remuneration for services over a defined period.

The adjudicator found no error in concluding that being on call, without performing services or receiving remuneration at the time of the accident, did not meet the statutory definition of employment.

The applicant sought statutory accident benefits for physical injuries she sustained while providing full-time attendant care to her husband, who was catastrophically impaired in a motor vehicle accident.

The respondent denied the benefits on the basis that the applicant was not involved in an 'accident'.

The Tribunal applied the two-part test from Caughy and found that the applicant's injuries did not arise out of the use or operation of an automobile, nor were they directly caused by it.

The Tribunal concluded that the injuries resulted from providing care, which broke the chain of causation.

The application was dismissed.

The applicant was injured in a motor vehicle accident while in the course of her employment.

She applied for accident benefits, but the insurer argued she was statute-barred under s. 61 of the Statutory Accident Benefits Schedule because she was entitled to WSIB benefits.

The applicant claimed she had elected to pursue a tort action, which would allow her to claim accident benefits under the s. 61(2) exception.

The Tribunal found that the applicant's election to sue in tort was not made in good faith, noting significant delays in pursuing the tort action, failure to notify the WSIB promptly, and ongoing appeals for WSIB benefits.

The Tribunal concluded the tort election was made solely for the purpose of claiming accident benefits, rendering her statute-barred.

The application was dismissed.

The applicant sought an income replacement benefit (IRB) following a motor vehicle accident.

Prior to the accident, the applicant worked on an on-call basis but had not worked for over six weeks before the collision.

The Licence Appeal Tribunal found that the applicant was not employed at the time of the accident within the meaning of section 5(1)(1)(i) of the Schedule, as she was not receiving remuneration for services during that period.

The application for an IRB and interest was dismissed.

The appellant appealed a Licence Appeal Tribunal decision finding she was not catastrophically impaired under s. 3.1(1) 2. iii of the Statutory Accident Benefits Schedule.

The appellant suffered a severe and permanent alteration of the structure of her leg, but her functional mobility impairment (measured by the SCIM) was only temporary.

The Divisional Court upheld the adjudicator's interpretation that the SABS requires both the structural and functional alterations to be permanent to meet the catastrophic impairment threshold.

The appeal was dismissed.

The insurer sought its expenses of $24,213.20 following an arbitration hearing where it successfully argued the applicant was not catastrophically impaired.

The arbitrator found there was divided success, as the applicant was only 1% away from the catastrophic impairment threshold and was successful on some treatment plans.

The insurer's offers to settle were not compliant with the Code as they were on a full and final basis.

Considering the criteria in the Code, the arbitrator ordered that each side bear its own expenses.

The applicant sought funding for a multidisciplinary catastrophic impairment assessment totaling $24,700 after being denied by the insurer.

The insurer argued the claim was statute-barred under s. 56 of the Schedule and that the assessments were not reasonable and necessary.

The Adjudicator found that catastrophic impairment assessments are not tied to a specific benefit, so the limitation period did not apply.

The Adjudicator also found the assessments reasonable and necessary to allow the applicant to obtain their own medical opinions, ordering the insurer to pay up to $2,000 per assessment and $200 for documentation, while denying duplicate entries.

The applicant, a taxi driver, sought reconsideration of a decision finding that his assault by a passenger over an unpaid fare was not an 'accident' under the Statutory Accident Benefits Schedule.

The applicant argued the adjudicator erred in applying the purpose and causation tests and failed to consider recent case law.

The Vice-Chair dismissed the request, finding no significant error of law or fact that would have changed the outcome, as the assault, not the use or operation of the vehicle, was the direct cause of the impairment.

The appellant insured's appeal regarding catastrophic impairment and income replacement benefits was previously dismissed.

The successful respondent insurer sought its appeal costs in the amount of $18,742.02.

The Director's Delegate reviewed the criteria under Rule 75.2 of the Dispute Resolution Practice Code, noting that the overriding consideration in fixing arbitration expenses is reasonableness.

Finding the claimed lawyer hours excessive for a non-complex appeal and the transcript costs unrecoverable, the Director's Delegate fixed the insurer's appeal expenses at $4,000.00 inclusive of disbursements and HST.

The appellant was injured in a 2006 motor vehicle accident and sought funding for six catastrophic impairment rebuttal reports in 2015.

The insurer paid $2,000 per report under the new SABS (2010), but the appellant claimed the balance, arguing the old SABS (1996) applied because his right to a rebuttal report had vested.

The Director's Delegate dismissed the appeal, holding that section 268(1) of the Insurance Act and the transitional provisions of the SABS clearly apply the $2,000 cap to assessments conducted after August 31, 2010, regardless of the accident date.

The concept of vested rights does not apply to statutory accident benefits.

The appellant appealed an Arbitrator's order requiring her to pay the respondent's arbitration expenses of $10,244.44 after she withdrew her application for accident benefits.

The appellant argued the Arbitrator erred in finding the respondent was entirely successful and that her counsel unduly prolonged the proceeding.

The Director's Delegate dismissed the appeal, finding that the withdrawal of all claims constituted complete success for the respondent and that there was evidence to support the finding that the appellant's counsel unduly prolonged the proceeding by failing to respond to correspondence.

The applicant sought expenses following an arbitration decision regarding statutory accident benefits.

The insurer argued for a reduced amount or that each party bear their own expenses due to divided success.

The arbitrator found the applicant was more successful overall and entitled to expenses.

Applying the principle of fairness and legal aid rates, the arbitrator fixed the applicant's expenses at $54,250.27 inclusive of fees, disbursements, and HST.

The applicant, a taxi driver, was assaulted by a passenger after leaving his vehicle and following the passenger into a laneway to collect an unpaid fare.

He applied for statutory accident benefits, which the respondent insurer denied on the basis that the incident was not an 'accident' under the Schedule.

The Licence Appeal Tribunal applied the two-part purpose and causation test from Greenhalgh.

The Tribunal found that leaving the taxi to collect a fare was not an ordinary use or operation of the vehicle, and that the assault was a distinct and severable intervening act that broke the chain of causation.

The application was dismissed.

Following a successful appeal regarding the addition of issues to existing arbitration proceedings after the transition date to the Licence Appeal Tribunal, the insurer sought its legal expenses of the appeal.

The Director's Delegate found that success was the only relevant criterion for entitlement under the Expense Regulation, as the issue was no longer novel.

The insureds were ordered to pay the insurer's appeal expenses, fixed at $4,000 inclusive of disbursements and HST.

The appellant insurer sought judicial review of a decision upholding an arbitrator's finding that the respondent insured was involved in an 'accident' under the Statutory Accident Benefits Schedule.

The insured, while using his vehicle as a taxi, was assaulted by a passenger, pushed, and slipped on ice while attempting to close the vehicle's door.

The Divisional Court dismissed the application, finding it was reasonable for the arbitrator and Director's Delegate to conclude that the incident arose out of the ordinary use or operation of an automobile and that the use or operation was a direct cause of the impairment, as the assault was not an intervening act that broke the chain of causation.

The applicant withdrew his application for accident benefits at the start of the arbitration hearing due to a potential capacity issue.

The insurer consented to the withdrawal but sought an expense hearing to recover its costs of $11,211.69.

The arbitrator found that the applicant's claim was not frivolous, vexatious, or an abuse of process.

Emphasizing that the Schedule is consumer protection legislation, the arbitrator concluded that the applicant should not be financially penalized for withdrawing the application and ordered that each party bear their own costs.

The applicant, who suffered a psychiatric impairment following a motor vehicle accident, sought funding for a $25,425 Catastrophic Impairment Assessment.

The insurer denied the claim, arguing the psychiatric condition was not caused by the accident and relying on multiple insurer examinations.

The Licence Appeal Tribunal found that while causation was questionable, it was reasonable and necessary for the applicant to explore the possibility of catastrophic impairment using his own assessors.

The Tribunal capped the funding at $12,200 pursuant to the Schedule's limits.

Claims for a special award and costs were dismissed.