Nicholas Maida

The appellant was struck by an uninsured motorcycle and suffered serious injuries.

She applied for statutory accident benefits 14 months after the accident, well beyond the 7-day notice period.

The License Appeal Tribunal found she did not have a reasonable explanation for the delay and barred her claim.

On appeal to the Divisional Court, the appellant argued the adjudicator erred in law by failing to address a prior LAT decision with similar facts.

The Divisional Court dismissed the appeal, holding that an administrative tribunal's failure to follow or expressly distinguish its own prior decisions does not constitute an error of law, and the adjudicator's weighing of the reasonable explanation factors was a question of mixed fact and law not subject to appeal.

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

The respondent raised a preliminary issue arguing the applicant was barred from proceeding because he failed to submit his application for benefits (OCF-1) within the prescribed time.

The Tribunal found that the applicant's father had notified the respondent of the accident within three days, satisfying the notice requirement under section 32(1) of the Schedule.

The respondent failed to fulfill its positive obligation to inquire and provide an accident benefits package under section 32(2), meaning the 30-day timeline to submit the OCF-1 was never triggered.

In the alternative, the Tribunal found the applicant had a reasonable explanation for the delay, as he had reached out to the respondent for assistance and received no response.

The applicant was permitted to proceed with his claim.

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

The respondent denied the claims and argued the applicant was barred from proceeding due to a late OCF-1 application.

The Tribunal found the applicant had a reasonable explanation for the delay due to confusing correspondence from the insurer.

On the merits, the Tribunal removed the applicant from the Minor Injury Guideline (MIG) due to an accident-related head injury.

The Tribunal denied dental expenses incurred before a treatment plan was submitted but awarded chiropractic services under an OCF-23, plus interest.

The claim for an award under s. 10 of Reg. 664 was dismissed.

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

The respondent denied benefits because the applicant failed to submit the OCF-1 application within the 30-day time limit prescribed by the Schedule.

The applicant argued that his health condition prevented him from submitting the form on time.

The Tribunal found that the applicant did not provide a reasonable explanation for the delay, noting a lack of corroborating medical evidence and the applicant's prior experience with the claims process.

The application was dismissed as statute-barred.

The applicant sought income replacement benefits (IRBs) following a motor vehicle accident, claiming an inability to perform his duties as a school bus driver.

The Licence Appeal Tribunal dismissed the application, finding the applicant failed to prove a substantial inability to perform the essential tasks of his employment for the pre-104 week period, noting inconsistencies between his physiotherapist's opinion and his family physician's records.

The Tribunal also found the applicant failed to submit a disability certificate in a timely manner and provided no evidence to support a complete inability to work for the post-104 week period.

The applicant requested a reconsideration of a Licence Appeal Tribunal decision that denied entitlement to two physiotherapy treatment plans, an orthopedic assessment, and an award.

The adjudicator granted the reconsideration in part, finding an error of fact regarding the January 12, 2024 physiotherapy treatment plan because the initial decision overlooked material clinical notes and records supporting the plan.

The applicant was found entitled to this plan plus interest.

The reconsideration requests for the other treatment plans and the award were dismissed, as the applicant had not provided submissions on them at the initial hearing or failed to establish an error.

The respondent's request for costs was denied because the reconsideration request was partially successful and not frivolous.

The applicant sought payment for an occupational therapy assessment under the Statutory Accident Benefits Schedule following a motor vehicle accident.

The respondent denied the benefit, arguing it was duplicative of two comprehensive occupational therapy assessments the applicant had already undergone in 2021.

The Tribunal found that the applicant failed to demonstrate that a further assessment was reasonable and necessary, as she did not provide evidence showing how the disputed assessment would gather new information or investigate a new condition.

The application was dismissed, and no interest was awarded.

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

The respondent insurer denied the claim, arguing the applicant failed to submit his application (OCF-1) within the 30-day timeframe prescribed by section 32(5) of the Schedule.

The Tribunal found that the respondent failed to meet its positive obligation under section 32(2) to assist the vulnerable applicant and provide the necessary forms, as it only left two voicemails and mailed a package to an incomplete address.

Consequently, the 30-day timeline was never triggered, and the applicant had a reasonable explanation for the delay.

The applicant was permitted to proceed with his claim.

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

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

The Tribunal found that the applicant failed to meet the burden of proving his injuries fell outside the MIG.

The Tribunal also rejected the applicant's argument that the respondent's denial letters were non-compliant with s. 38(8) of the Schedule, finding that citing the MIG constitutes a valid medical reason for denial.

The application was dismissed.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for physiotherapy and an orthopaedic assessment.

The respondent denied the benefits, initially relying on the Minor Injury Guideline (MIG), though the MIG was later conceded.

The Tribunal found the applicant entitled to the first physiotherapy treatment plan based on supportive clinical notes from his family physician.

However, the Tribunal dismissed the claims for subsequent physiotherapy plans and the orthopaedic assessment due to a lack of medical evidence demonstrating they were reasonable and necessary.

The claim for a special award under s. 10 of O. Reg. 664 was dismissed as the insurer's conduct did not rise to the level of being unreasonable, given the applicant's failure to provide requested medical documentation.

The applicant sought statutory accident benefits following a motor vehicle accident in August 2022, claiming entitlement to a non-earner benefit and two physiotherapy treatment plans.

The respondent denied the benefits, arguing the applicant's impairments stemmed from a prior 2019 accident and that he did not suffer a complete inability to carry on a normal life.

The Tribunal found the applicant's evidence highly inconsistent regarding his pre- and post-accident functioning and employment status.

Relying on the consistent evidence of the respondent's assessors and the applicant's own treating records, the Tribunal concluded the applicant failed to prove his entitlement to the non-earner benefit or the treatment plans.

The application was dismissed, and the respondent's request for costs due to late service of documents was also denied.

The applicant requested a reconsideration of a preliminary issue decision which barred her from proceeding with her application for accident benefits due to a 14-month delay in submitting her OCF-1.

The applicant argued the Tribunal failed to properly weigh her personal circumstances as an unsophisticated person, erred in assessing prejudice to the respondent, and failed to address analogous case law.

The Vice-Chair dismissed the request, finding that the Tribunal had appropriately considered the applicant's circumstances and the prejudice to the insurer, and that the failure to cite a specific case did not constitute a material error of law or fact that would have changed the outcome.

The applicant was injured as a pedestrian in a motor vehicle accident but did not notify the insurer or submit an application for accident benefits (OCF-1) until 14 months later.

The insurer raised a preliminary issue that the claim was statute-barred due to the delay.

The Tribunal found that the applicant failed to provide a reasonable explanation for the delay, noting that her ignorance of the law and focus on her injuries did not justify the entire 14-month period.

Furthermore, the delay caused incurable prejudice to the insurer, as the applicant sustained multiple intervening injuries that prevented a contemporaneous assessment of the accident-related impairments.

The application was dismissed.

An appeal from an arbitration decision under the Insurance Act concerning priority of payment of statutory accident benefits.

The claimant, a 25-year-old who suffered severe traumatic brain injury in a motorcycle accident, was deemed catastrophically impaired.

The arbitrator determined that the claimant was principally dependent on his sister, who was insured by the appellant, rather than on his parents or the motorcycle insurer.

The appeal challenged the arbitrator's application of the dependency test, arguing that the arbitrator failed to properly apply all four criteria from the leading case and failed to conduct a precise calculation of the 51% threshold.

The court upheld the arbitrator's decision, finding no error of law or palpable and overriding error in the arbitrator's reasoning and factual conclusions.

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

The insurer argued the applicant was statute-barred from proceeding with her claim because she failed to submit her application for benefits (OCF-1) within 30 days, as required by s. 32(5) of the Schedule.

The Tribunal found that the insurer failed to comply with its obligation to provide the forms under s. 32(2) because it sent them via email without the applicant's consent, contrary to s. 64(2)(e).

Furthermore, the Tribunal held that the applicant had a reasonable explanation for the delay due to her post-concussion syndrome, difficulties with screens, and the insurer's communications suggesting a late submission was acceptable.

The applicant was permitted to proceed with her claim.

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

The Licence Appeal Tribunal considered claims for chiropractic services, psychological services, and a chronic pain assessment.

The Tribunal found the applicant was entitled to the outstanding balances for chiropractic services and the chronic pain assessment, as they were reasonable and necessary.

The claim for psychological services was dismissed due to a lack of evidence demonstrating a psychological impairment.

Interest was awarded on the overdue payments.

The applicant sought entitlement to a psychological assessment treatment plan and an award for unreasonable delay following a motor vehicle accident.

The adjudicator dismissed the application, finding the applicant failed to prove the assessment was reasonable and necessary.

The adjudicator preferred the objective testing and comprehensive assessments of the respondent's psychological experts over the applicant's pre-screening report and treating records, which lacked contemporaneous psychological complaints.

The adjudicator also found the respondent's denial letter complied with the notice requirements under s. 38(8) of the Schedule.

The applicant sought statutory accident benefits following a motor vehicle accident, disputing the insurer's denial of treatment plans for physiotherapy, a social work assessment, and an orthopaedic assessment.

The applicant argued the insurer's denial notices were procedurally defective under s. 38(8) of the Schedule.

The Tribunal found the insurer's denial notices were compliant and properly relied on an Insurer's Examination report.

As the applicant failed to provide submissions on the substantive reasonableness and necessity of the plans, the application was dismissed.

The insurer's request for costs due to the inadvertent inclusion of a settlement document was also denied.

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

The Tribunal found that the applicant was not entitled to $2,200.00 for minor injury guideline (MIG) treatment and supplementary goods because the MIG limit had already been exhausted prior to changing clinics.

However, the Tribunal found that a treatment plan for physical therapy in the amount of $3,622.73 was reasonable and necessary based on the medical evidence.

The applicant's claim for a special award was dismissed as there was no evidence the insurer unreasonably withheld benefits.

The applicant sought entitlement to statutory accident benefits for various treatment plans, including chiropractic services, a biopsychosocial assessment, a driving evaluation, and a chronic pain assessment, following a motor vehicle accident.

The respondent denied the benefits on the basis that the applicant had reached maximum medical recovery and that her ongoing complaints were related to subsequent, non-accident incidents.

The Licence Appeal Tribunal found that the applicant failed to provide objective medical evidence to demonstrate that the proposed treatment plans were reasonable and necessary as a result of the accident.

The application was dismissed, and no interest was awarded.