Nathalie V. Rosenthall

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 insurer sought repayment of $9,673.38 in income replacement benefits (IRBs) paid to the respondent, alleging the respondent made untrue statements about his employment.

The insurer also sought recovery of $2,353.93 in accountant fees and costs of the proceeding.

The respondent did not participate in the hearing.

The Tribunal found that the respondent's claims were untrue and ordered repayment of the IRBs plus interest under section 52 of the Statutory Accident Benefits Schedule.

However, the Tribunal held it lacked jurisdiction to order repayment of the insurer's adjustment costs, including accountant fees.

The insurer's request for costs was denied as the respondent's non-participation did not impose additional costs on the insurer.

The applicant insurer sought repayment of benefits and claim adjustment costs from the respondent, alleging he wilfully misrepresented being a passenger in an insured vehicle during an accident.

The respondent did not participate in the hearing.

The Tribunal found that the respondent was not an occupant of the vehicle and that his claim was based on a wilful misrepresentation.

The Tribunal ordered the respondent to repay $200.00 in benefits plus interest.

However, the Tribunal held it lacked jurisdiction to order repayment of the insurer's claim adjustment costs, such as insurer's examination fees, and denied the insurer's request for costs of the proceeding.

The applicant sought non-earner benefits following a motor vehicle accident.

The respondent denied the benefits based on insurer's examinations which concluded the applicant did not suffer a complete inability to carry on a normal life.

The Tribunal preferred the detailed reports of the respondent's assessors over the brief letter from the applicant's family physician.

The Tribunal found the applicant was able to continue his pre-accident activities and dismissed the claim for non-earner benefits, interest, and costs.

The applicant insurer applied to the Licence Appeal Tribunal for repayment of statutory accident benefits paid to the respondent, alleging he was not a passenger in the insured vehicle at the time of the accident.

The Tribunal found that the respondent made a wilful misrepresentation, as evidence showed he was not an occupant of the vehicle.

The respondent was ordered to repay $2,400.00 in benefits plus interest.

However, the Tribunal dismissed the insurer's claim for reimbursement of adjusting and examination costs, finding no authority in the Schedule to order repayment of such expenses.

The insurer's request for costs of the proceeding was also dismissed.

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 sought accident benefits following a motor vehicle accident.

The insurer terminated income replacement benefits and sought repayment, alleging the applicant misrepresented her employment status.

The applicant failed to produce ordered employment records and did not attend the hearing.

Her counsel was permitted to withdraw due to a breakdown in the solicitor-client relationship.

The arbitrator dismissed the applicant's claims and ordered her to repay $18,914.29 in income replacement benefits, finding she wilfully misled the insurer about her work history.

The insurer was also awarded $3,500 in costs.

The applicant was injured in a motor vehicle accident and sought various medical, rehabilitation, and attendant care benefits from her insurer.

The insurer initially denied several treatment plans on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG), but later conceded her injuries were outside the MIG following an insurer's examination.

The Tribunal found that the applicant was entitled to the disputed physiotherapy and chiropractic treatment plans, as well as the cost of an attendant care assessment, because her injuries, which included chronic pain syndrome, warranted treatment outside the MIG.

However, the Tribunal dismissed the applicant's claims for replacement eyeglasses and out-of-pocket physiotherapy and acupuncture expenses due to a lack of supporting evidence connecting them to the accident or complying with the requirement to submit a treatment plan.

The applicant's request for costs was also dismissed.

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.

This was a costs endorsement following dismissal of a third party's motion for leave to bring a motion and for a medical examination.

The plaintiffs sought costs, but costs had not been addressed before the judge who dismissed the underlying motion retired.

The court held that it would decide the costs issue and permitted the parties to make further brief written submissions by a fixed deadline.

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.

The applicant was injured in a motor vehicle accident and applied for statutory accident benefits from Unifund Assurance Company based on a fraudulent pink insurance slip provided by the owner of the vehicle he was driving.

Unifund refused to respond, arguing there was no nexus between it and the applicant.

The arbitrator held that the applicant's choice of insurer was not arbitrary or random, as he relied on the police report which listed Unifund based on the fraudulent slip.

Therefore, a sufficient nexus existed, and Unifund was the first insurer required to pay benefits pending any priority dispute.

The applicant sought a preliminary order to exclude several insurer's medical reports and prohibit their authors from testifying at an upcoming arbitration hearing.

The applicant argued that the insurer was not entitled to request further assessments under section 42 of the Schedule after having previously terminated income replacement benefits based on a WAD II diagnosis.

The arbitrator dismissed the motion, finding that an insurer has an ongoing right and obligation to assess a claim as it progresses, particularly when new medical information suggests the injuries may be more severe than initially diagnosed.

The exclusion of evidence was deemed an extraordinary remedy not justified in these circumstances.

The Applicant, injured in a motor vehicle accident, sought statutory accident benefits and applied for arbitration.

At a pre-hearing, the Applicant requested an order for the production of particulars related to surveillance conducted by the Insurer, regardless of whether the Insurer intended to rely on it at the hearing.

The Arbitrator, bound by a previous appeal decision, held that the Insurer is not obligated to disclose surveillance evidence unless and until it decides to rely upon it at the arbitration hearing.

The request for production was denied.