Marni E. Miller

The appellant was injured in a motor vehicle collision and submitted a claim for prescription medication to her auto insurer.

The insurer required her to undergo a medical examination under section 44 of the Statutory Accident Benefits Schedule to determine if the expense was reasonable and necessary.

When the appellant refused, the Licence Appeal Tribunal barred her from disputing the denial of her claim.

On appeal, the Divisional Court held that the Tribunal erred in its statutory interpretation, finding that insurers cannot require section 44 examinations for prescription medication claims because such claims are not submitted through treatment and assessment plans.

The applicant sought a non-earner benefit (NEB) and payment for multiple treatment plans following a 2017 motor vehicle accident.

The Licence Appeal Tribunal found that the applicant's entitlement to a NEB was not triggered because he failed to submit a completed disability certificate within the required 104-week timeframe and did not provide a reasonable explanation for the delay.

The Tribunal also dismissed the claims for the treatment plans, preferring the respondent's insurer examination reports which concluded the requested psychological, chronic pain, physiotherapy, and occupational therapy services were not reasonable and necessary.

Claims for an award and interest were also dismissed.

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

The respondent scheduled psychological and occupational therapy insurer's examinations (IEs).

The applicant attended both, but the psychologist passed away before finalizing his report, and the applicant declined to participate in the situational portion of the occupational therapy IE.

The respondent scheduled a second set of IEs, which the applicant refused to attend.

The Tribunal found that a second in-person psychological IE was not reasonably necessary, as the respondent possessed the draft report and raw data.

However, the Tribunal found the situational occupational therapy assessment was reasonably necessary.

The Tribunal stayed the proceeding until the applicant complied with the situational assessment requirement.

The applicant sought reconsideration of a preliminary decision which barred her from commencing a proceeding for certain medical benefits due to her failure to attend an insurer's examination under section 44 of the Statutory Accident Benefits Schedule.

The applicant argued the Tribunal erred in law regarding the application of section 55(2), the availability of an insurer's examination for prescription medication, and by failing to provide adequate reasons.

The Tribunal allowed the late-filed amended reconsideration request but ultimately dismissed the reconsideration, finding no significant errors of law or fact that would have changed the outcome and concluding that adequate reasons were provided in the initial decision.

The applicant was involved in a motor vehicle accident and sought statutory accident benefits, including a determination of catastrophic impairment due to a mental or behavioural disorder.

The respondent denied the benefits, arguing the applicant's psychological impairments pre-dated the accident.

The Tribunal found that the accident exacerbated the applicant's pre-existing condition, resulting in a marked class 4 impairment in her adaption to the workplace.

The Tribunal concluded the applicant was catastrophically impaired and awarded attendant care benefits of $931.57 per month, along with partial entitlement to claimed medical, rehabilitation, and examination expenses.

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

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

The Tribunal found that the applicant was statute-barred from disputing two of the treatment plans because the insurer had provided clear and unequivocal denials more than two years prior to the application.

On the merits, the Tribunal concluded that the applicant failed to establish that her injuries, including alleged chronic pain and psychological issues, fell outside the MIG.

Consequently, the applicant was bound by the $3,500 funding limit, and the remaining treatment plan was denied.

Claims for an award and interest were also dismissed.

The applicant sought medical benefits for occupational therapy and chiropractic treatment following a motor vehicle accident where they were struck as a pedestrian.

The Licence Appeal Tribunal found that the occupational therapy plan was not reasonable and necessary as it proposed case management services to which the applicant was not entitled, and there was no evidence of cognitive issues.

The Tribunal also dismissed the claims for chiropractic treatment, finding no supporting medical evidence and noting that the applicant had mostly recovered.

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

The applicant sought statutory accident benefits following a motor vehicle accident, disputing the insurer's denial of several treatment plans and medical expenses.

The Licence Appeal Tribunal found that the insurer's denial complied with s. 38(8) of the Schedule by adequately relying on an Insurer's Examination report.

The Tribunal partially allowed the claim for an aqua therapy program, limiting recovery to pool sessions incurred after the treatment plan was submitted and at the rate for an unregulated provider.

Claims for chiropractic laser therapy and orthotics were dismissed for lack of evidence, while a prescription expense for migraine medication was allowed.

The applicant's request for a special award under Ontario Regulation 664 was dismissed as the insurer's reliance on the medical assessment was not unreasonable.

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

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

The applicant argued the insurer was precluded from relying on the MIG due to prior approvals, and alternatively, that her pre-existing obesity and alleged post-concussion syndrome removed her from the MIG.

The Tribunal held the insurer provided proper notice and was not precluded from applying the MIG.

The Tribunal further found the applicant failed to provide compelling evidence that her obesity was a documented pre-existing condition that prevented recovery within the MIG cap, or that she suffered a concussion caused by the accident.

The appeal was dismissed.

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

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

The Tribunal found that the respondent's notice of denial was boilerplate and failed to provide sufficient medical reasons as required by section 38(8) of the Schedule.

Consequently, under section 38(11), the respondent was prohibited from taking the position that the MIG applied and was liable to pay the disputed benefit.

The applicant's claim for a special award was dismissed because the applicant had delayed disclosing a subsequent accident, meaning the respondent did not unreasonably withhold payment.

The respondent insurer requested a reconsideration of a Tribunal decision that permitted the applicant's appeal for income replacement benefits to proceed despite being filed six days after the two-year limitation period.

The Tribunal had applied section 7 of the Licence Appeal Tribunal Act to extend the time.

On reconsideration, the Vice-Chair found no error of law or fact in the original decision, confirming that section 7 of the LAT Act prevails over the mandatory limitation period in section 56 of the SABS, and that the Tribunal properly applied the four-factor test for extending time.

The request for reconsideration was denied.

The applicant was injured in a motor vehicle accident and sought income replacement benefits (IRBs) and the cost of a psychological assessment.

The adjudicator found that the applicant failed to prove that her inability to work was caused by the accident, noting significant pre-accident and post-accident medical issues unrelated to the collision.

The adjudicator accepted the respondent's medical assessments that the applicant could perform the essential tasks of her pre-accident employment.

While the adjudicator found the psychological assessment was necessary, the claim was dismissed because the applicant failed to prove the proposed fees were reasonable under the Professional Services Guideline.

The application was dismissed.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits from the insurer.

After the applicant passed away, her legal counsel was removed from the record as no Estate Trustee had been appointed to provide instructions.

The insurer brought a motion to dismiss the arbitration application.

As no one appeared or responded on behalf of the applicant's estate, the arbitrator found that continuing the proceeding would be an abuse of process.

The application for arbitration was dismissed without costs.

Aviva sought repayment of $14,514 in Income Replacement Benefits (IRB) and $5,537 in insurer examination expenses from the respondent, whose auto policy was voided for failing to disclose that his partner, who had a poor driving record, had moved in with him.

The Tribunal found that the respondent intentionally failed to notify Aviva of a material change in risk, entitling Aviva to repayment of the IRB under s. 52(1)(b) of the Statutory Accident Benefits Schedule.

However, the Tribunal dismissed Aviva's claim for reimbursement of insurer examination expenses, finding no statutory basis for such recovery.

No costs were awarded.

The respondent brought a motion to exclude a medical report filed by the applicant after the deadline set in a case conference order.

The applicant argued the report was merely supplementary to an earlier report.

The Tribunal found that admitting the report without allowing the respondent to respond would be prejudicial.

To balance the applicant's right to present her case with the respondent's right to procedural fairness, the Tribunal granted the motion in part by adjourning the hearing to allow the respondent to have the applicant assessed and to respond to the late report.

The applicant insurer brought a motion for an immediate order of prohibition staying a Licence Appeal Tribunal (LAT) proceeding pending judicial review.

The insurer sought judicial review of the LAT's decision to deny its requests to adjourn a written hearing regarding the respondent's entitlement to statutory accident benefits.

The Divisional Court dismissed the motion, finding that the insurer failed to meet the RJR-MacDonald test for a stay, as there was no serious issue to be tried and no irreparable harm.

The court also held that the motion was premature, as it offended the general rule against judicial interference with ongoing administrative processes.

The applicant, who was injured in a 2009 motor vehicle accident, applied for arbitration regarding statutory accident benefits.

Following the applicant's reported death in 2015, no estate representative came forward.

The arbitrator issued a Notice of Intent to Dismiss, allowing 40 days for a response.

After receiving no reply from the applicant's family or estate, and upon the insurer's request, the arbitrator dismissed the applications for arbitration, finding the continued silence rendered the proceedings vexatious and an administrative burden.

The applicant sought a non-earner benefit and a rehabilitation benefit following a motor vehicle accident.

The adjudicator excluded late-filed medical reports submitted by the applicant in reply, finding their admission would prejudice the respondent.

Applying the Heath test, the adjudicator found the applicant failed to prove a complete inability to carry on a normal life, as evidence showed she continued to perform most of her pre-accident caregiving and household activities.

The claim for the rehabilitation benefit was dismissed for lack of evidence that it was reasonable and necessary.

Claims for interest, costs, and a special award were also dismissed.

The insurer brought a preliminary motion to preclude the insured applicants from mediating their accident benefits disputes because they failed to attend insurer's examinations (IEs).

The applicants had refused to attend the IEs unless the insurer provided a MAG-accredited Cantonese interpreter.

The arbitrator found that the applicants' demand for a MAG-accredited interpreter was unreasonable.

However, the arbitrator held that the applicants were not precluded from mediation under s. 55(2) of the Statutory Accident Benefits Schedule because the insurer's notices of examination were defective.

The notices failed to provide the 'medical and any other reasons' for the examinations as required by s. 44(5).

Despite this, the arbitrator awarded $750 in expenses to the insurer because the applicants' unreasonable insistence on a MAG-accredited interpreter and their delay in raising the defective notice issue prolonged the proceedings.

The applicant applied for statutory accident benefits following a motor vehicle accident.

After failing to attend a pre-hearing discussion, the applicant was given notice of the arbitration hearing but again failed to appear.

The arbitrator proceeded in the applicant's absence pursuant to Rule 37.7 of the Dispute Resolution Practice Code.

As no evidence was presented to support the claim, the application was dismissed.

The applicant was ordered to pay the insurer's expenses in the amount of $960.78.