OLAT 2018

The applicant sought medical benefits for three treatment plans following a motor vehicle accident.

The insurer denied the plans based on insurer examinations concluding the applicant had reached maximum medical recovery and that his impairments were not attributable to the accident.

The Tribunal found that the applicant had a pre-existing condition of degenerative disc disease and failed to provide sufficient medical evidence demonstrating that the accident aggravated this condition or caused the current impairments.

Relying on the persuasive reports of the insurer's examiners, the Tribunal concluded the treatment plans were not reasonable and necessary.

The application was dismissed.

The applicant sought payment for a psychological assessment, interest, and a special award following a motor vehicle accident.

The Licence Appeal Tribunal dismissed the claims, finding the applicant failed to provide a detailed breakdown of the assessment costs to prove they were reasonable and necessary.

The Tribunal also found the assessment report lacked cogent analysis to support its diagnoses.

Consequently, claims for interest and a special award for unreasonable delay were also dismissed.

The applicant requested an adjournment of a three-day in-person hearing because the respondent insurer's psychology expert witness was unavailable.

The respondent did not consent to the adjournment.

The Tribunal granted the adjournment, noting that the applicant has the right to cross-examine the expert witness.

The applicant was injured in a motor vehicle accident and received income replacement benefits (IRBs) for 104 weeks.

The respondent terminated IRBs on the basis that the applicant did not meet the post-104 week test of a complete inability to engage in any suitable employment.

The applicant applied to the Licence Appeal Tribunal for dispute resolution.

The Tribunal found the applicant's evidence regarding his pain levels to be unreliable, noting evidence of symptom exaggeration and malingering from the respondent's expert assessors.

The Tribunal concluded the applicant failed to prove he suffered a complete inability to engage in suitable employment and dismissed the claims for IRBs, interest, and a special award.

The applicant sought a catastrophic impairment determination under the mental and behavioural disorder criteria following a motor vehicle accident.

The insurer requested a neuropsychological and psychological insurer examination (IE), which the applicant refused to attend, citing severe psychological distress from previous IEs.

The Tribunal held that the applicant is precluded from proceeding with his appeal on the catastrophic determination until the insurer completes the requested IE.

The Tribunal found the IE was reasonably necessary to assess the new catastrophic impairment claim, but imposed conditions on how the IE must be conducted to protect the applicant's psychological well-being.

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

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

The Licence Appeal Tribunal found that the applicant failed to meet the burden of proving that his physical or psychological injuries fell outside the MIG.

The Tribunal preferred the evidence of the respondent's psychological assessor and the applicant's treating family physician over the applicant's psychological expert.

As the injuries were predominantly minor, the application for disputed treatment plans, interest, and a special award was dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident, specifically claiming attendant care benefits and the cost of an in-home assessment.

The Licence Appeal Tribunal dismissed the application, finding that the in-home assessment cost was incurred prior to submitting a treatment plan and while the applicant was under the Minor Injury Guideline.

The Tribunal also found that the applicant was not entitled to attendant care benefits because no expenses were actually incurred, and the insurer did not unreasonably delay or withhold payment.

Claims for an award under Regulation 664 and interest were also dismissed.

The applicant was injured in a rear-end motor vehicle accident and sought statutory accident benefits for a psychological assessment and a chronic pain treatment program.

The respondent insurer denied both claims, initially relying on the Minor Injury Guideline.

The Licence Appeal Tribunal found that the applicant demonstrated psychological symptoms and chronic pain related to the accident that warranted the disputed treatment plans.

The Tribunal preferred the evidence of the applicant's assessor over the respondent's paper-review expert, noting inconsistencies in the latter's reports.

The Tribunal ordered the respondent to pay for both the psychological assessment and the chronic pain treatment program, along with interest on the overdue payments.

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

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

The Licence Appeal Tribunal found that the medical evidence established the applicant suffered predominantly minor soft tissue injuries.

The applicant failed to provide compelling medical evidence of a pre-existing condition that would prevent maximal recovery under the MIG cap.

The application for medical benefits and examination costs beyond the $3,500 limit was dismissed.

The applicant was injured when a Toronto Transit Commission bus suddenly stopped, causing her to fall and fracture her right arm.

She applied for a non-earner benefit and an attendant care benefit, which the respondent denied.

The Licence Appeal Tribunal found that the applicant did not suffer a complete inability to carry on a normal life, as medical and surveillance evidence showed she could still engage in substantially all of her pre-accident activities.

The Tribunal also denied the attendant care benefit because the applicant failed to submit an Assessment of Attendant Care Needs form prior to the claimed period and did not prove she required assistance beyond the date the form was eventually submitted.

The application was dismissed.

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

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

The Tribunal found that the applicant's psychological symptoms, including post-traumatic stress disorder, removed her from the MIG.

The Tribunal ordered the respondent to pay for the disputed chiropractic and psychological treatment plans, as well as the cost of a psychological assessment, finding them reasonable and necessary.

The applicant's claim for an award for unreasonably delayed payments was dismissed for lack of evidence.

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

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

The Tribunal found that while the injuries were predominantly minor, the applicant's pre-existing condition of chronic lymphocytic leukemia, which was documented prior to the accident via glandular swelling, prevented maximal recovery under the MIG.

The applicant was therefore excluded from the MIG.

The Tribunal ordered the insurer to pay for two chiropractic treatment plans, an in-home assessment, and a functional abilities assessment, finding them reasonable and necessary, but denied a $108.00 chiropractic claim that exceeded the FSCO Professional Service Guideline.

The applicant was injured in a motor vehicle accident and sought various statutory accident benefits, which the respondent insurer denied on the basis that her injuries fell within the Minor Injury Guideline (MIG).

The applicant argued she should be removed from the MIG due to pre-existing hypothyroidism and psychological impairments.

The Tribunal found that the applicant failed to provide compelling evidence that her pre-existing condition prevented her from achieving maximal recovery within the MIG cap, preferring the respondent's psychological assessment over the applicant's.

All claims for benefits were dismissed, and the applicant was ordered to pay $200 in costs for repeatedly filing evidence late.

The respondent, a self-employed dump truck driver, was injured in a motor vehicle accident and received income replacement benefits (IRB) from the applicant insurer.

The insurer sought repayment of an alleged overpayment, arguing that collateral disability benefits received by the respondent should have been deducted.

The respondent disputed the deductibility of the collateral benefits and sought ongoing IRB up to the 104-week mark.

The Tribunal found that the collateral benefits were income continuation benefits and therefore deductible, entitling the insurer to repayment subject to the 12-month notice period.

However, the Tribunal also found that the respondent remained substantially unable to perform the essential tasks of his employment and was entitled to ongoing IRB up to the 104-week mark.

The applicant sought income replacement benefits (IRBs) following a motor vehicle accident, claiming he suffered from chronic pain that prevented him from working as a carpenter apprentice.

The adjudicator dismissed the application, finding the applicant's evidence and his expert's chronic pain assessment unreliable due to inconsistencies with the medical records, including evidence of prior injuries, altercations, and drug use.

The adjudicator preferred the respondent's orthopaedic and functional assessments, concluding the applicant failed to prove a substantial inability to perform his pre-accident employment for the pre-104 week period, or a complete inability to engage in suitable employment for the post-104 week period.

Claims for an award and interest were also dismissed.

The applicant was injured in a motor vehicle accident and sought medical benefits for exercise equipment, assistive devices, a chronic pain assessment, and chiropractic services under the Statutory Accident Benefits Schedule.

The respondent insurer denied the benefits.

The Licence Appeal Tribunal dismissed the application, finding that the applicant relied solely on self-reporting of pain without corroborating medical documentation.

The Tribunal preferred the evidence of the respondent's insurer examination assessors, who concluded that the requested treatments and assessments were not reasonable and necessary.

As no benefits were payable, the claims for interest and an award were also dismissed.

The applicant sought an extension of time under section 7 of the Licence Appeal Tribunal Act to commence a proceeding for statutory accident benefits after missing the two-year limitation period.

The applicant initially filed for mediation at FSCO but failed to re-file with the Tribunal in a timely manner after the mediation was deemed failed.

The adjudicator applied the four-part test for extending time and found no reasonable explanation for the delay, noting that the respondent would be prejudiced by the passage of time.

The request for an extension of time was denied and the application was dismissed.

The applicant sought a $10,000 death benefit from the respondent insurer after their 48-year-old adult child, who had a developmental disability, died following a pedestrian-vehicle collision.

The insurer denied the benefit, arguing the deceased lived independently.

The Tribunal found that the deceased was principally dependent on the applicant for care, as the applicant coordinated support services, provided daily emotional support, and assisted with essential needs like clothing, diet, and transportation.

The Tribunal ordered the insurer to pay the death benefit plus interest.

The applicant was injured in a rear-end motor vehicle accident and sought attendant care and medical benefits.

The adjudicator found the applicant was statute-barred from claiming attendant care benefits because the application was filed beyond the two-year limitation period.

Furthermore, the adjudicator determined the applicant's injuries fell within the Minor Injury Guideline (MIG) based on medical evidence and self-reporting, and that she had exhausted the $3,500 limit for medical and rehabilitation benefits.

All claims for additional treatment, assessments, and interest were dismissed.

The applicant was injured in a motor vehicle accident and sought medical benefits for physiotherapy.

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

The applicant argued she suffered from chronic pain and other conditions that warranted removal from the MIG.

The Tribunal found that the applicant's injuries were predominantly minor and that her ongoing back pain was likely related to degenerative changes and a subsequent workplace fall, rather than the accident.

As the injuries fell within the MIG, the appeal for further medical benefits was dismissed.