Michelle Furtado Jorge

The respondent insurer requested a reconsideration of a Tribunal decision that awarded the applicant ongoing income replacement benefits (IRBs).

The insurer argued the Tribunal exceeded its jurisdiction and breached procedural fairness because only the quantum of the IRB, not ongoing entitlement, was in dispute.

The adjudicator dismissed the request, finding that the application, case conference report, and the parties' own submissions clearly indicated that ongoing entitlement was a live issue.

The adjudicator confirmed there was no error of law or breach of procedural fairness.

The applicant sought statutory accident benefits following a 2019 motor vehicle accident.

The respondent denied a chiropractic treatment plan and the cost of a walker.

The applicant appealed to the Licence Appeal Tribunal after the two-year limitation period expired.

The Tribunal applied the Manuel factors and extended the limitation period under section 7 of the Licence Appeal Tribunal Act, finding merit in the appeal and no prejudice to the respondent.

However, on the substantive issues, the Tribunal dismissed the claims, finding the chiropractic plan and walker were not reasonable and necessary as a result of the accident.

The applicant was injured in a motor vehicle accident and sought various statutory accident benefits, including an income replacement benefit (IRB), attendant care benefits, and payment for treatment plans.

The respondent stopped paying the IRB based on an accounting report that deducted speculative Canada Pension Plan Disability (CPP-D) amounts.

The Tribunal found that vacation pay and pre-accident earnings should be included in the IRB calculation, and that speculative CPP-D amounts could not be deducted, entitling the applicant to an ongoing IRB.

The Tribunal denied the claim for attendant care benefits because the applicant failed to prove the expenses were incurred.

The Tribunal approved an in-home occupational therapy assessment as reasonable and necessary, but denied a small balance for physiotherapy services that exceeded the maximum hourly rate.

Claims for a special award and costs were dismissed, but interest was awarded on overdue benefits.

The applicant sought statutory accident benefits following a 2013 motor vehicle accident, including a home modifications assessment, yoga therapy, medical cannabis, and various physical therapies.

The respondent insurer denied the treatment plans.

The Licence Appeal Tribunal dismissed the application, finding the applicant failed to prove the treatments were reasonable and necessary.

The Tribunal noted the home modification assessment exceeded statutory limits and lacked safety justification, the yoga therapy duplicated approved attendant care, the applicant derived no benefit from medical cannabis, and physical therapies were ineffective for her resolved physical injuries.

The applicant was injured in a motor vehicle accident and received income replacement benefits (IRBs) from the respondent insurer.

The respondent subsequently discovered the applicant was concurrently receiving long-term disability benefits, which reduced the IRB quantum to zero.

The respondent sought repayment of $54,552.79 in overpaid IRBs.

The Tribunal found the respondent provided timely notice of the overpayment within 12 months of the lump-sum payment, as required by section 52 of the Schedule.

The Tribunal rejected the applicant's argument that the insurer was restricted to recovering the overpayment via a 20% clawback from future IRBs, noting the provision is permissive and the applicant was not currently receiving IRBs.

The respondent was awarded the full repayment amount plus interest.

The applicant requested a reconsideration of a Licence Appeal Tribunal decision that partially denied her claims for treatment plans under the Statutory Accident Benefits Schedule.

The applicant argued that the Tribunal violated procedural fairness by refusing to consider her late reply submissions and by asking factual questions after the hearing.

She also alleged errors of law regarding the application of the Minor Injury Guideline and claimed there was new evidence.

The Vice-Chair dismissed the request, finding no procedural unfairness as the applicant missed the mandated deadline for reply submissions.

The Vice-Chair also found no error of law, noting the applicant was attempting to reargue her case, and concluded that the applicant failed to identify any new evidence that met the test for reconsideration.

The applicant sought statutory accident benefits following a motor vehicle accident, disputing the insurer's denial of several treatment plans (OCF-18s) and an expense for a mouth guard.

The Tribunal found that the insurer properly denied a $3,696.50 chiropractic treatment plan under s. 38(5) of the Schedule because the applicant was subject to the Minor Injury Guideline at the time.

The Tribunal partially approved a physiotherapy treatment plan for $199.50, finding it reasonable and necessary based on the recommendation of a chronic pain specialist.

The remaining treatment plans and expenses were dismissed as the applicant failed to discharge her evidentiary onus to demonstrate they were reasonable and necessary.

Interest was awarded on the overdue payment.

The applicant sought various statutory accident benefits following a motor vehicle accident, including attendant care, physiotherapy, transportation expenses, and housekeeping benefits.

The Licence Appeal Tribunal dismissed the application in its entirety.

The Tribunal found that the applicant failed to prove the attendant care expenses were incurred or that the provider suffered an economic loss.

Further attendant care claims were denied as not reasonable and necessary, supported by surveillance footage contradicting the applicant's reported limitations.

The physiotherapy claim was dismissed because it had already been paid by a collateral benefits carrier.

Transportation expenses for gas, lottery tickets, and water were denied as they did not meet the 50-kilometer threshold for authorized transportation.

Finally, the housekeeping claim was dismissed because the applicant had not sustained a catastrophic impairment.

The applicant requested a reconsideration of a decision that denied payment for various medical expenses under the Statutory Accident Benefits Schedule.

The applicant argued the adjudicator erred in law and fact by failing to consider his unique circumstances.

The Licence Appeal Tribunal dismissed the request, finding that the applicant was attempting to re-litigate unsuccessful arguments and failed to identify an articulable error of law or fact that would have changed the outcome.

The applicant sought various statutory accident benefits following a 2015 motor vehicle accident, including attendant care, chiropractic treatment, medication, and multiple assessments.

The Tribunal found that the claims for attendant care and initial chiropractic treatment were statute-barred by the two-year limitation period, and the applicant failed to establish reasonable grounds for an extension.

For the remaining substantive claims, the Tribunal concluded the applicant had not met her burden to prove the treatments and assessments were reasonable and necessary, preferring the evidence of the respondent's medical examiners who opined the applicant had reached maximum medical recovery.

The application was dismissed.

The applicant, who sustained catastrophic impairments in a motor vehicle accident, sought payment for various medical and rehabilitation benefits, including a 3D mattress system, a portable modulation stimulator, naturopathic treatments, and an infrared sauna.

The respondent denied the claims primarily on the basis that the expenses were incurred prior to the submission of treatment plans (OCF-18s) or were experimental and not reasonable and necessary.

The Tribunal found that section 38 of the Schedule barred recovery for most of the expenses incurred prior to submission.

The Tribunal also accepted the respondent's expert evidence that certain treatments were experimental.

The application was allowed in part for an eye exam and specific wellness products, but the majority of the claims and the request for costs were dismissed.

The applicant, who was catastrophically impaired in a motor vehicle accident, sought payment for various assessment costs under the Statutory Accident Benefits Schedule.

The insurer denied portions of the treatment plans on the basis that they exceeded the $2,000 cap per assessment under s. 25(5)(a) or were for provider travel expenses not covered under s. 25(4).

The Tribunal agreed with the insurer, finding that the applicant failed to demonstrate the reasonableness of the unapproved portions, including attempts to bifurcate assessments to circumvent the fee cap.

The application 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 sought statutory accident benefits after her adult son was killed in a motorcycle accident.

The respondent denied the claim on the basis that the applicant was not an 'insured person' under the policy.

The applicant was not the named insured, a designated driver, or a spouse, and argued she was a dependant of the named insured (her son's friend).

The Tribunal found no evidence that the applicant was principally dependent for financial support or care on the named insured.

The application was dismissed as the applicant failed to prove she was an insured person under the Schedule.

The applicant, who was catastrophically impaired following a motor vehicle accident, sought payment for a psychovocational assessment, winter tires, and a wellness retreat in British Columbia.

The Licence Appeal Tribunal found that the psychovocational assessment was not payable as it was incurred prior to the submission of the treatment plan and was not reasonable and necessary given the volume of existing medical opinions.

The Tribunal also held that winter tires do not constitute a vehicle modification under the Schedule and that the wellness retreat was not reasonable and necessary.

The application was dismissed.

The applicant sought statutory accident benefits after her adult son was killed in a motorcycle accident.

The respondent denied the claim on the basis that the applicant was not an 'insured person' under the policy.

The applicant was the owner of the motorcycle, but the named insured was a friend of her son, and the applicant was not a named insured, designated driver, or spouse.

The Tribunal found that the applicant failed to prove she was principally dependent for financial support or care on the named insured.

The application was dismissed.

The applicant requested a reconsideration of a Tribunal decision that denied two treatment plans for case manager services, including $600 for mileage.

The applicant argued the Tribunal erred in fact and law by not determining whether the mileage expenses were necessary and by finding the treatment plan unreasonable.

The Tribunal dismissed the request, finding that the applicant was merely re-arguing submissions from the original hearing without demonstrating any error in fact or law.

The applicant sought reconsideration of a Tribunal decision denying entitlement to certain chiropractic services and a psychiatric assessment following a motor vehicle accident.

The Tribunal had denied the chiropractic services because the applicant failed to attend a reasonably requested insurer's examination, triggering a statutory bar to proceeding.

The psychiatric assessment was denied because the expense was incurred before the treatment plan was submitted, contrary to the Statutory Accident Benefits Schedule.

On reconsideration, the adjudicator found no significant errors of law or fact in the original decision that would have led to a different result.

The request for reconsideration was dismissed.

The applicant requested a reconsideration of a Licence Appeal Tribunal decision that denied entitlement to various treatment plans and assessment costs following a motor vehicle accident.

The applicant argued the Tribunal failed to properly weigh medical evidence, ignored arguments about previously paid treatment, and failed to provide reasons for denying specific treatment plans.

The Vice Chair dismissed the request, finding that the Tribunal had properly considered and weighed the evidence, addressed the applicant's arguments, and provided sufficient reasons for denying all the treatment plans in dispute.

The applicant, who sustained a catastrophic impairment in a motor vehicle accident, sought payment for case management services (CMS) under the Statutory Accident Benefits Schedule.

The insurer partially denied a 2015 CMS plan based on the Professional Services Guideline limits and fully denied a 2018 CMS plan, arguing the applicant no longer required the services.

The Licence Appeal Tribunal dismissed the appeal, finding the insurer was not liable for amounts exceeding the Guideline limits for the 2015 plan.

For the 2018 plan, the Tribunal preferred the insurer's nursing assessment, which demonstrated the applicant's current capacity to independently manage her treatment and rehabilitation, concluding the CMS was not reasonable and necessary.