OLAT 2017

The applicant was injured in a motor vehicle accident and sought a medical benefit of $698.83 for the denied portions of a psychological treatment plan, specifically for documentation support and three additional progress evaluations.

The Licence Appeal Tribunal found that the applicant failed to explain the documentation fee and that the request for four progress evaluations over twelve sessions exceeded the Ontario Psychological Association Guidelines.

The application was dismissed as the applicant did not prove the treatment plan was reasonable and necessary.

The applicants were injured in a motor vehicle accident during the course of their employment.

They elected to opt out of the Workplace Safety and Insurance Act (WSIA) scheme to join a class action lawsuit against the Province of Newfoundland and Labrador, and subsequently claimed statutory accident benefits from the respondent.

When the class action was dismissed, the respondent terminated their accident benefits, arguing the applicants were required to seek WSIA compensation since they no longer had a viable court action.

The Tribunal held that the applicants' election to sue was made in good faith and not primarily for the purpose of claiming accident benefits.

The Tribunal further found that the legislation does not permit a retroactive reassessment of the election based on the ultimate outcome of the civil litigation, and ordered that the applicants remain entitled to accident benefits.

The applicant, who was catastrophically impaired in a motor vehicle accident, lacked the mental capacity to proceed with their application for statutory accident benefits.

The applicant was impecunious and unable to afford a formal guardianship application.

The applicant brought a motion to resume the case conference.

The Licence Appeal Tribunal, noting it lacked a specific rule for appointing a litigation guardian, adopted the process used by the Social Justice Tribunals Ontario.

The Tribunal ordered the case conference to resume once the applicant provided a signed declaration from a proposed litigation guardian meeting specific criteria.

The applicant, who suffered catastrophic impairment in a motor vehicle accident, sought a rehabilitation benefit of $6,698.64 for travel expenses to visit family in Iran, accompanied by an attendant care provider.

The insurer denied the claim.

The Licence Appeal Tribunal dismissed the application, finding that the travel was not a necessary expense under section 16 of the Statutory Accident Benefits Schedule, nor was it a permitted type of travel expense, as it did not have a counselling or training purpose.

Claims for interest and costs were also dismissed.

The applicant was struck by a city bus as a pedestrian, sustaining soft tissue injuries and a mild traumatic brain injury.

She subsequently developed severe depression, anxiety, and post-traumatic stress disorder.

She applied for a determination that her impairments met the catastrophic threshold under the Statutory Accident Benefits Schedule.

The Tribunal found that while her cognitive complaints were largely psychogenic rather than organic, her psychological impairments were genuine and severely debilitating.

Relying on comprehensive neuropsychological and occupational therapy assessments, the Tribunal concluded the applicant suffered a marked impairment in the adaptation domain, thereby meeting the criteria for a catastrophic impairment under s. 2(1.2)(g) of the Schedule.

The applicant sought attendant care benefits (ACBs) and interest following a motor vehicle accident.

The respondent initially denied the benefits based on an occupational therapy assessment.

The adjudicator found that the applicant's medical evidence, including clinical notes from her family doctor and a pain consultant, established her entitlement to ACBs.

The adjudicator also found that the expenses were deemed incurred after August 2015 because the respondent unreasonably withheld payment.

The respondent was ordered to pay ACBs of $873.30 per month from July 16, 2015 to September 30, 2016, plus interest.

The applicant sought statutory accident benefits following a motor vehicle accident, but the insurer denied further payments on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG) and the $3,500 limit had been reached.

The applicant argued that his injuries were not predominantly minor due to psychological impairments, physical injuries including chronic pain, and pre-existing conditions.

The Licence Appeal Tribunal found that the applicant failed to prove on a balance of probabilities that he suffered from a psychological impairment, a non-minor physical injury, or a pre-existing condition that would prevent maximal recovery under the MIG.

Consequently, the applicant was not entitled to the disputed medical benefits and assessments.

The applicant, a pedestrian struck by a vehicle, sought statutory accident benefits including attendant care, chiropractic services, and assessments.

The respondent insurer denied the benefits, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) and its $3,500 cap.

The applicant contended that chronic pain and psychological impairments took her outside the MIG.

The Tribunal found that the applicant's soft tissue injuries had resolved and that she failed to prove her chronic pain or psychological symptoms were more than mere sequelae of the minor injuries.

Consequently, the MIG applied, precluding attendant care benefits and limiting assessment costs.

The claims were largely dismissed, save for a potential $215 payment for a psychological assessment if it constituted a first visit.

The respondent insurer requested a reconsideration of a Licence Appeal Tribunal decision that granted the applicant entitlement to a chronic pain assessment.

The insurer argued that the Tribunal erred in law by applying a standard of proof based on a 'balance of possibilities' rather than a 'balance of probabilities.' The Executive Chair agreed, finding that the Tribunal explicitly applied the wrong standard of proof when assessing whether the assessment was reasonable and necessary.

The reconsideration request was granted, and the matter was remitted to the same Tribunal member for redetermination using the correct balance of probabilities standard.

The applicant's request for costs was denied.

The applicant was injured in a motor vehicle accident and received income replacement benefits until the respondent terminated them in June 2014.

The applicant applied to the Licence Appeal Tribunal for dispute resolution in July 2016, beyond the two-year limitation period.

The applicant argued the limitation period should be tolled due to mental incapacity.

The Tribunal found insufficient evidence to establish the onset of mental incapacity prior to the expiry of the limitation period, noting that the applicant's counsel had determined he had capacity to instruct her when filing the application.

The application was dismissed as statute-barred.

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

The respondent insurer denied the claims, arguing the injuries fell within the Minor Injury Guideline (MIG) and that a claim for $1,165.00 in physiotherapy services was statute-barred.

The Tribunal found that the applicant's injuries were predominantly minor, as there was no compelling medical evidence of a pre-existing condition that would prevent maximal recovery within the MIG cap.

Furthermore, the Tribunal dismissed the claim for physiotherapy services because the applicant failed to file the application within the two-year limitation period.

The respondent insurer brought a preliminary motion to dismiss the applicant's claim for statutory accident benefits on the basis that the applicant failed to attend multiple scheduled insurer's examinations.

The applicant argued that the notices of examination were not compliant with the Statutory Accident Benefits Schedule.

The Tribunal found that the notices were compliant and that the applicant's failure to attend was unjustified.

The application was dismissed pursuant to section 55 of the Schedule.

The Tribunal declined to order reimbursement of non-attendance fees, finding no jurisdiction to do so.

The applicant was injured in a motor vehicle accident and sought attendant care benefits, medical benefits, and the cost of examinations under the Statutory Accident Benefits Schedule.

The Tribunal found the applicant was entitled to attendant care benefits for the initial period as the expenses were properly incurred, but denied benefits for the subsequent period based on the applicant's admissions of self-sufficiency and surveillance evidence.

Several treatment plans, including those for a TMJ assessment, chiropractic services, an orthopaedic assessment, and a chronic pain assessment, were deemed reasonable and necessary given the applicant's chronic pain and objective medical evidence.

Other treatment plans were denied for lack of supporting evidence.

The respondent's request for costs was dismissed.

The applicant was injured in a motor vehicle accident and sought medical and rehabilitation benefits, as well as the cost of a vocational assessment, from her auto insurer.

The insurer denied the claims, arguing the injuries were uncomplicated soft tissue injuries and not related to the accident.

The Licence Appeal Tribunal found that the objective medical evidence, including CT and MRI scans, established that the applicant suffered from disc herniation and radiculopathy caused by the accident.

The Tribunal concluded that the requested physiotherapy, chiropractic, psychological services, and vocational assessment were reasonable and necessary.

The applicant was awarded the claimed benefits with interest, and no costs were awarded to either party.

The applicant sought payment for chiropractic and psychological treatment plans following a motor vehicle accident.

The respondent insurer argued it was not liable due to the applicant's failure to provide requested medical records under s. 33 of the Schedule.

The Tribunal found the requested information was not reasonably required, as the insurer had already denied the claims on their merits.

However, on the substantive issues, the Tribunal dismissed the application, finding that neither treatment plan was reasonable and necessary given the preponderance of medical evidence, including multiple insurer examinations indicating no further need for treatment and a lengthy gap in seeking treatment.

The respondent's request for costs was also denied.

The applicant was injured in a motor vehicle accident in 2008.

In 2010, the respondent insurer denied ongoing attendant care and housekeeping benefits beyond the 104-week mark unless the applicant was determined to be catastrophically impaired.

The applicant did not dispute this denial within the two-year limitation period.

In 2015, the applicant applied for and was granted a catastrophic impairment designation, and subsequently sought ongoing benefits.

The respondent denied the claims on the basis that the initial denial was not disputed in time.

The Tribunal found that the 2010 denial was clear and unequivocal, triggering the two-year limitation period.

The Tribunal rejected the applicant's arguments that the denial was invalid because she had not yet been found catastrophically impaired, and that the discoverability principle applied.

The application was dismissed as statute-barred.

The applicant sought a non-earner benefit and a medical benefit for chiropractic services following a motor vehicle accident.

The Licence Appeal Tribunal dismissed the claim for a non-earner benefit, finding the applicant failed to prove a complete inability to carry on a normal life, noting insufficient evidence of pre- and post-accident activities and surveillance footage showing her performing daily tasks.

However, the Tribunal granted the medical benefit for chiropractic services, finding it reasonable and necessary as the applicant continued to suffer from accident-related impairments and chronic pain syndrome.

Interest was denied as the treatment had not yet been incurred.

The applicant, a 72-year-old retiree, sought non-earner benefits following a motor vehicle accident.

The insurer denied the claim based on insurer's examinations.

The Tribunal applied the Heath test to compare the applicant's pre- and post-accident activities.

The Tribunal found that while the applicant experienced some pain and psychological distress, she failed to prove a complete inability to carry on a normal life, as she continued to participate in her pre-accident activities.

The application for non-earner benefits was dismissed.

The applicant was struck by a motor vehicle as a pedestrian and sought statutory accident benefits for chiropractic services.

The respondent insurer denied the treatment plans, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Licence Appeal Tribunal found that the applicant's injuries, which included chronic pain, fell outside the MIG based on the detailed medical evidence of her chronic pain specialist.

The Tribunal ordered the respondent to pay the disputed medical benefits, finding them reasonable and necessary, along with interest on the overdue amounts.

The applicant sought medical and rehabilitation benefits for chronic pain treatment and physiotherapy following a motor vehicle accident.

The respondent insurer denied the treatment plans on the basis that the applicant had reached maximum medical improvement.

The Licence Appeal Tribunal found that the applicant's medical evidence lacked precision and failed to link the proposed treatments to the accident or demonstrate how they would improve his function.

Relying on the respondent's medical assessors, who concluded the applicant's injuries had resolved, the Tribunal held the treatment plans were not reasonable and necessary.

The claim for a chronic pain assessment was also dismissed because the applicant failed to submit the required Treatment and Assessment Plan (OCF-18).

The application was dismissed in its entirety.