OLAT 2017

The applicant sought statutory accident benefits following a motor vehicle accident, disputing the insurer's determination that her injuries fell within the $3,500 Minor Injury Guideline (MIG) limit.

The adjudicator found that while the applicant's physical injuries were predominantly soft-tissue and she did not suffer a diagnosable psychological impairment, she was nevertheless removed from the MIG limit because the insurer's notice failed to explicitly state its belief that the MIG applied, breaching section 38(9) of the Schedule.

Consequently, the applicant was awarded the outstanding balance of an incurred chiropractic plan and reimbursement for prescription expenses.

However, claims for a psychological assessment and a further chiropractic plan were dismissed as not reasonable and necessary.

The applicant sought statutory accident benefits following a motor vehicle accident, including income replacement benefits (IRBs) and two treatment plans.

The respondent insurer denied the benefits, arguing the applicant did not meet the test for IRBs and failed to attend scheduled independent medical examinations (IEs).

The Tribunal found the applicant's credibility lacking due to her failure to produce documents explaining her non-attendance at the IEs and drew an adverse inference.

However, relying on the applicant's psychological expert, the Tribunal concluded she suffered severe psychological impairments rendering her substantially unable to perform the essential tasks of her pre-accident employment as a personal support worker.

The Tribunal awarded ongoing IRBs, excluding the period of non-attendance at the IEs, but denied the disputed treatment plans as duplicative or unproven.

The applicant sought a rehabilitation benefit of $2,200 for a treatment and assessment plan following a motor vehicle accident.

The respondent denied the plan, arguing it was not reasonable and necessary.

The applicant argued the plan should be deemed approved because the respondent failed to respond within the required 10 days under section 38 of the SABS.

The Tribunal found that the applicant failed to prove the treatment was reasonable and necessary, relying on an independent occupational therapy assessment that found no functional limitations.

Furthermore, although the respondent was late in responding, the applicant had not actually incurred the expenses, so there was no entitlement to payment under the deemed approval provisions.

The application was dismissed.

The applicant sought statutory accident benefits after being assaulted by several men with a sword in a pizzeria parking lot.

He was struck while outside his vehicle and while attempting to escape inside it.

The insurer denied the claim on the basis that the incident was not an 'accident' under section 3(1) of the Statutory Accident Benefits Schedule.

The Licence Appeal Tribunal held a preliminary issue hearing and found that the direct cause of the applicant's injuries was the intervening assault, not the use or operation of his vehicle.

The Tribunal dismissed the application, as well as both parties' claims for costs and the applicant's claim for a special award.

The applicant sought an income replacement benefit (IRB) following a motor vehicle accident.

The insurer raised a preliminary issue that the applicant failed to apply for the benefit within 104 weeks of the accident.

The Tribunal found that the applicant did submit a completed disability certificate within the 104-week period, satisfying the application requirement.

However, on the substantive issue, the Tribunal dismissed the claim because the applicant failed to provide sufficient medical evidence demonstrating a substantial inability to perform the essential tasks of his employment during the first 104 weeks, which is a prerequisite for claiming post-104 week IRBs.

The applicant sought statutory accident benefits for chiropractic, psychological, and occupational therapy services following a 2006 motor vehicle accident.

The insurer denied the treatment plans and raised a preliminary issue that the plans were initially unsigned.

The Tribunal held that the insurer waived the signature requirement by failing to raise it in the initial denial letters.

On the merits, the Tribunal found the chiropractic and occupational therapy plans were reasonable and necessary to address the applicant's chronic pain, though mileage expenses for the occupational therapist were excluded.

The psychological treatment plans were denied due to insufficient evidence of ongoing psychological distress and the applicant's failure to attend previously approved sessions.

The applicant sought attendant care benefits following a motor vehicle accident.

The Tribunal found that while the applicant's physical injuries fell within the Minor Injury Guideline (MIG), her psychological impairments (Major Depressive Disorder and Generalized Anxiety Disorder) took her outside the MIG.

However, the claim for attendant care benefits was dismissed because the applicant failed to prove the expenses were 'incurred' under section 3(7)(e) of the Schedule.

The evidence regarding care provided by family members was vague, lacked corroboration, and failed to establish economic loss or that the care was provided in the course of ordinary employment.

The applicant was injured in a motor vehicle accident and sought payment for a psychological assessment and physiotherapy services.

The respondent insurer denied the treatment plans on the basis that the applicant's injuries were predominantly minor and subject to the $3,500 cap under the Minor Injury Guideline (MIG).

The Tribunal found that the applicant failed to provide sufficient medical evidence to prove her chronic pain, fibromyalgia, and psychological impairments were caused by the accident or removed her from the MIG.

The application was dismissed, and the applicant was denied the claimed benefits, interest, and costs.

The applicants, adult children of a woman seriously injured in a motor vehicle accident, sought payment for social worker assessments under the Statutory Accident Benefits Schedule.

The insurer denied the treatment plans and requested independent medical examinations, which the applicants failed to attend.

The Tribunal held that the insurer was not automatically required to pay for the assessments under s. 38(11) because they were incurred outside the applicable time period.

Furthermore, the Tribunal dismissed the applications pursuant to s. 55(1) of the Schedule because the applicants failed to attend the required independent medical examinations.

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

The insurer denied the claims, and the applicant appealed to the Licence Appeal Tribunal.

The Tribunal found that the applicant failed to comply with the prescribed timelines for submitting her income replacement benefit claim and was therefore barred from appealing its denial.

However, the Tribunal ordered the insurer to pay the costs of two medical assessment plans because the insurer failed to provide the required notice of refusal within 10 business days under section 38(8) of the Schedule.

The applicant's request for an award for unreasonable delay was denied.

The applicant sought Income Replacement Benefits (IRBs) following two separate motor vehicle accidents.

The insurer denied the benefits and the applicant applied to the Licence Appeal Tribunal for dispute resolution.

The insurer brought a preliminary issue hearing arguing the applications were barred by the two-year limitation period.

The Tribunal found that the insurer had provided clear and unequivocal denials of the IRBs, along with the required dispute resolution options, more than two years before the applications were filed.

The Tribunal declined to extend the limitation period, finding no reasonable grounds to do so, and dismissed the applications as statute-barred.

The applicant sought statutory accident benefits following a motor vehicle accident, disputing the insurer's determination that his injuries fell within the Minor Injury Guideline (MIG) and seeking payment for a psychological assessment.

The Licence Appeal Tribunal found that the applicant failed to prove his psychological and physical injuries were not predominantly minor, as the psychological assessment relied upon was subjective and inconsistent with objective test results.

Consequently, the applicant's benefits remained capped at $3,500 under the MIG.

However, the Tribunal found the psychological assessment was a reasonable and necessary expense, ordering the insurer to pay for it, with interest, provided there were remaining funds within the applicant's MIG limit.

The applicant was injured in a motor vehicle accident and sought income replacement benefits (IRBs) and medical benefits for physiotherapy and assistive devices.

The Licence Appeal Tribunal found that the applicant was substantially unable to perform the essential tasks of his pre-accident employment as a marble shop worker, which involved medium physical demand level work, and granted the IRBs.

However, the Tribunal denied the medical benefits for physiotherapy due to a lack of specificity in the treatment plan, and denied the assistive devices because there was no evidence linking the applicant's foot pathology to the accident.

Interest was awarded on the overdue IRBs.

The self-represented applicant sought payment for a chiropractic treatment plan in the amount of $4,493.71 following a 2007 motor vehicle accident.

The applicant claimed she suffered from whiplash, fibromyalgia, and 'windy poison'.

The adjudicator found that the applicant failed to provide persuasive evidence linking her fibromyalgia and 'windy poison' to the accident.

While whiplash was verified as a direct result of the accident, the applicant provided no objective medical opinion supporting that chiropractic treatment would improve her condition, whereas the respondent's orthopaedic assessment concluded treatment would not help.

The application was dismissed as the treatment plan was not shown to be reasonable and necessary.

The applicant sought medical and rehabilitation benefits following a motor vehicle accident.

The respondent denied treatment and assessment plans for chiropractic services, a social service assessment, and an orthopaedic assessment.

The Tribunal found that the applicant failed to prove the chiropractic services and orthopaedic assessment were reasonable and necessary, largely due to insufficient evidence and an unreliable affidavit from her chiropractor.

However, the Tribunal approved the social service assessment, finding it reasonable and necessary to address the applicant's relationship and job-related issues caused by the accident.

Interest was awarded on the overdue amount, and the respondent's request for costs was denied.

The applicant was injured in a motor vehicle accident and sought payment for three examination expenses: a functional abilities evaluation, a social emotional assessment, and an attendant care assessment.

The Tribunal found the functional abilities evaluation to be reasonable and necessary, awarding $2,152.00 plus interest.

The social emotional assessment and attendant care assessment were denied as a duplication of services and for failing to meet the evidentiary onus, respectively.

The Tribunal also awarded $125.00 in costs to the respondent due to the applicant's unreasonable late filing of submissions and evidence.

The applicant, an eight-year-old with severe pre-existing disabilities, was struck by a vehicle and sustained a traumatic brain injury.

He applied for a determination of catastrophic impairment under s. 3(2)(d)(ii) of the Statutory Accident Benefits Schedule, arguing that the accident significantly increased his dependency and need for daily support.

The respondent argued that the accident did not exacerbate his pre-existing impairments.

The Tribunal found the applicant's evidence, including his mother's testimony and the Omega Medical Associates assessment, more compelling.

The Tribunal concluded that the applicant's condition worsened significantly after the accident, increasing his dependencies, and deemed him catastrophically impaired.

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

The insurer denied certain benefits, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Licence Appeal Tribunal found that the applicant suffered from chronic pain that caused significant functional impairment, thereby removing her from the MIG.

The Tribunal ordered the insurer to pay for disputed occupational therapy and chiropractic treatment plans, finding them reasonable and necessary.

However, the Tribunal dismissed the applicant's claim for ongoing income replacement benefits, concluding she failed to prove a substantial inability to perform the essential tasks of her pre-accident employment.

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

The respondent insurer raised preliminary issues, arguing the applicant was statute-barred from proceeding before the Licence Appeal Tribunal due to failing to provide information requested under section 33 of the Schedule and failing to attend an insurer's examination under section 44.

The Tribunal found that failure to comply with section 33 does not preclude an applicant from disputing a refusal to pay benefits, and regardless, the applicant had complied with the reasonable requests.

Furthermore, the Tribunal held the applicant was not barred for failing to attend the insurer's examination because the respondent's notice was non-compliant, as it explicitly stated attendance was not required.

The applicant, who was injured in a motor vehicle accident, sought statutory accident benefits for social worker support, an in-home occupational therapy assessment, and travel costs for a service provider.

The Licence Appeal Tribunal found that the social worker support duplicated an already approved psychological treatment plan and was therefore not reasonable and necessary.

The Tribunal also found the in-home assessment was not reasonable and necessary based on independent medical examinations.

Finally, the Tribunal held that the Statutory Accident Benefits Schedule does not require insurers to pay travel costs for service providers.

The application was dismissed.