OLAT 2018

The applicant sought income replacement benefits following a motor vehicle accident.

The insurer argued the applicant was barred from proceeding because he failed to attend three requested medical and vocational examinations.

The Tribunal found the insurer provided sufficient notice for the orthopaedic assessment but not for the functional abilities or job site evaluations.

Consequently, the applicant is barred from proceeding with his claim until he attends the orthopaedic assessment.

The Tribunal also awarded the applicant 25 per cent of a delayed benefit payment under Regulation 664, but denied his request for costs.

The applicant was involved in a motor vehicle accident and sought medical benefits and the cost of examinations from the respondent insurer.

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

The applicant argued that his neck injuries and headaches warranted removal from the MIG.

The Tribunal found that the applicant failed to establish a causal link between the accident and the findings on a neck MRI conducted three years later.

The Tribunal also found that the applicant's headaches were clinically associated sequelae of his minor sprain and strain injuries.

As the applicant failed to prove his injuries fell outside the MIG, and the disputed benefits exceeded the funding cap, the application was dismissed.

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

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

The applicant argued that he suffered more than minor injuries, including a foot/ankle injury, cognitive dysfunction, and psychological damage.

The Tribunal found that the applicant failed to meet his burden of proving that his injuries were more than predominantly minor, as there was insufficient objective medical evidence linking his alleged impairments to the accident.

Furthermore, the Tribunal concluded that the disputed treatment plans were not reasonable and necessary.

The application was dismissed.

The respondent insurer sought reconsideration of a case conference order denying its request for the production of photographs taken by the applicant after a slip and fall incident.

The insurer argued the adjudicator erred by refusing to order production of a relevant document.

The Vice-Chair denied the reconsideration request, finding that the insurer failed to demonstrate how the photographs were relevant or material to determining whether the incident constituted an accident under the Statutory Accident Benefits Schedule.

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

The respondent denied claims for non-earner benefits, attendant care benefits, and a neurological assessment.

The applicant filed an application for dispute resolution with the Licence Appeal Tribunal after the limitation period had expired.

The Tribunal applied the Manuel factors under section 7 of the Licence Appeal Tribunal Act and granted an extension of time, finding that the applicant had a bona fide intention to appeal, the delay was not significant, the respondent was not prejudiced, and the appeal had merit given the applicant's recent catastrophic impairment designation.

The applicant was injured in a motor vehicle accident and sought medical benefits and income replacement benefits (IRB) from the respondent insurer.

The adjudicator found that the applicant's physical and psychological injuries fell within the Minor Injury Guideline (MIG) and were subject to the $3,500 funding limit, as the applicant failed to prove pre-existing conditions or psychological injuries that would exempt him.

Consequently, the disputed treatment plans were denied.

The adjudicator also dismissed the claim for IRB, finding the applicant did not provide sufficient medical evidence to prove a substantial inability to perform the essential tasks of his employment as a taxi driver.

The applicant, a cyclist injured in a motor vehicle accident, sought Income Replacement Benefits (IRBs) after the respondent insurer terminated them.

The adjudicator reviewed the medical evidence, including multiple Insurer's Examinations, which concluded the applicant could perform the essential tasks of his pre-accident employment as a prep cook/dishwasher.

The applicant failed to provide contradictory medical evidence to meet his burden of proof.

The application for both pre-104 week and post-104 week IRBs was dismissed.

The applicant, injured in a motor vehicle accident, brought a motion for interim attendant care and housekeeping benefits pending a hearing on catastrophic impairment.

The Licence Appeal Tribunal dismissed the motion, finding it lacks jurisdiction to grant interim orders for payment of accident benefits under the amended Insurance Act, as no regulation has been created to provide such power.

The respondent's request for costs was also dismissed.

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

The respondent insurer denied the claims, arguing the applicant had reached maximal medical recovery.

The Licence Appeal Tribunal found the physiotherapy treatment plan reasonable and necessary, noting the applicant had not pursued surgery due to age-related risks and had not reached maximal medical recovery.

However, the Tribunal denied the request for an orthopaedic assessment, finding it duplicative of a recent examination by an orthopaedic consultant and lacking compelling evidence of a need for further assessment.

The applicant sought income replacement benefits (IRBs) following a motor vehicle accident.

The respondent terminated the IRBs after the applicant returned to work and provided notice of the termination.

More than two years later, the applicant stopped working and sought to reinstate the IRBs.

The Tribunal held that the applicant was statute-barred from appealing the denial because the two-year limitation period commenced upon the clear termination notice, and subsequent inquiries by the respondent did not reset the limitation period.

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

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

The applicant argued that he suffered from chronic post-traumatic headaches and post-concussion syndrome, which would remove him from the MIG.

The Tribunal found that the applicant failed to prove on a balance of probabilities that he suffered from post-concussion syndrome, noting a lack of ongoing medical treatment and his quick return to full-time work.

The Tribunal concluded that the applicant's injuries were predominantly minor and dismissed the application.

The applicant sought funding for a multidisciplinary catastrophic impairment assessment after exhausting the $50,000 non-catastrophic limit for medical and rehabilitation benefits.

The respondent insurer denied the treatment plan, arguing that the non-catastrophic limit applied and that sufficient medical documentation already existed.

The Tribunal held that the cost of catastrophic assessments is not subject to the $50,000 non-catastrophic limit under section 18(3) of the Schedule, but rather falls under section 25.

The Tribunal found the requested assessments reasonable and necessary, but denied the separate fees for file and medical document review, finding them to be an inherent component of the assessments subject to the $2,000 cap per assessment.

The applicant sought non-earner benefits following a motor vehicle accident, claiming a complete inability to carry on a normal life.

The applicant had a significant pre-accident medical history, including fibromyalgia, which had previously rendered her unable to work.

The Tribunal reviewed medical evidence, including insurer examinations and surveillance footage, which demonstrated that the applicant was able to engage in most of her pre-accident activities of daily living.

The Tribunal found that the applicant's ongoing impairments were largely attributable to her pre-existing conditions and dismissed the application for non-earner benefits.

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

The respondent denied income replacement benefits and medical benefits, arguing the applicant failed to attend a required section 44 insurer examination and that his injuries fell within the Minor Injury Guideline.

The Tribunal found the applicant was statute-barred under section 55(2) of the Schedule for failing to attend the scheduled ophthalmology examination.

In the alternative, the Tribunal found the applicant's injuries were predominantly minor, he had exhausted the Minor Injury Guideline limits, and he failed to establish a substantial inability to perform the essential tasks of his employment.

The applicant sought reconsideration of a Licence Appeal Tribunal decision that dismissed his application for income replacement benefits as statute-barred.

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

The Associate Chair found no error in the Tribunal's conclusion that mental incapacity was not established at the relevant time.

However, the Associate Chair found the Tribunal made a significant error of law by failing to consider its discretion to extend the limitation period under s. 7 of the Licence Appeal Tribunal Act, 1999.

Applying the factors for an extension of time, the Associate Chair granted the extension, noting the applicant's declining capacity, the short delay, lack of prejudice to the insurer, and the merits of the claim.

The respondent insurer requested a reconsideration of a Licence Appeal Tribunal decision that found the applicant entitled to an income replacement benefit following a motor vehicle accident.

The insurer argued the Tribunal ignored evidence of the applicant's pre-accident intentions and post-accident work, misapplied the causation test, and heard false or misleading evidence.

The Associate Chair dismissed the request, finding that the omitted evidence would not have changed the outcome and that the insurer failed to pursue the evidence during the written hearing.

The reconsideration request was denied.

The insurer requested a reconsideration of a Licence Appeal Tribunal decision that awarded the insured physiotherapy services, orthopaedic and psychiatric assessments, and a special award under s. 10 of Regulation 664.

The Executive Chair found no significant error of law in the adjudicator's determination that the treatment plans and assessments were reasonable and necessary for managing the insured's chronic pain.

However, the Executive Chair allowed the reconsideration regarding the s. 10 award, finding that the adjudicator erred by conflating the reasonableness of the treatment plans with the unreasonableness of the insurer's conduct.

The award was overturned as there was no evidence the insurer unreasonably withheld or delayed payments.

The applicant sought statutory accident benefits following a motor vehicle accident, claiming entitlement to two treatment plans for chronic pain and physiotherapy that were denied by the insurer.

Following a reconsideration order, the Licence Appeal Tribunal reheard the matter and found that the applicant suffered from chronic pain syndrome, supported by credible self-reporting and medical evidence.

The Tribunal concluded that both treatment plans were reasonable and necessary to treat the applicant's chronic pain and functional impairments.

The insurer was ordered to pay the disputed amounts of $9,464.40 and $1,312.63, along with interest on the overdue benefits.

The applicant sought reconsideration of a Licence Appeal Tribunal decision denying his claim for accident benefits at the Michigan Personal Injury Protection level.

On reconsideration, the applicant raised a new argument that he should receive benefits under his spouse's policy with a different insurer, effectively disputing priority.

The Executive Chair dismissed the request, holding that a reconsideration is not an avenue for advancing new arguments that could have been made earlier, and that the time limit to dispute priority between insurers had expired.

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

The respondent denied a non-earner benefit and certain medical benefits, asserting the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found that the applicant's accident-related injuries were minor and subject to the $3,500 funding limit, noting that pre-existing degenerative issues did not preclude recovery within the MIG.

The Tribunal also dismissed the claim for a non-earner benefit, finding insufficient evidence of a complete inability to carry on a normal life.

The application was dismissed.