OLAT 2018

The applicant sought case management services following a motor vehicle accident, relying on the purchase of an optional catastrophic impairment benefit under s. 28(1) 5 of the Statutory Accident Benefits Schedule.

The applicant had not been deemed catastrophically impaired.

The Licence Appeal Tribunal held that the plain language of s. 17(1)(b) read with s. 28(1) 5 requires both the purchase of the optional benefit and a catastrophic impairment designation to trigger entitlement to case management services.

The preliminary issue was resolved in favour of the respondent.

The applicant was involved in two separate motor vehicle accidents in February 2015 and April 2016.

She sought medical and rehabilitation benefits beyond the $3,500 limit of the Minor Injury Guideline (MIG) for both accidents, arguing she suffered psychological injuries and had pre-existing conditions.

The Licence Appeal Tribunal found that the applicant failed to provide compelling medical evidence of a psychological diagnosis or a pre-existing condition that would prevent maximal recovery if subjected to the MIG limits.

Consequently, the Tribunal held that the applicant's injuries for both accidents fell within the MIG, and she was not entitled to the disputed treatment plans.

The applicant sought an income replacement benefit (IRB) following a 2011 motor vehicle accident.

The insurer denied the claim in March 2012.

The applicant did not dispute the denial until December 2017, after exhausting collateral benefits.

The Tribunal held that the two-year limitation period began running with the clear and unequivocal 2012 denial.

The Tribunal declined to extend the limitation period under s. 7 of the Licence Appeal Tribunal Act or apply estoppel, finding no bona fide intention to appeal within the time limit and no prejudice caused by the insurer's subsequent conduct.

The application was dismissed as time-barred, and the applicant's request for costs was denied.

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

The respondent denied a treatment plan for physiotherapy on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG).

The applicant argued she should be removed from the MIG due to a pre-existing condition of scoliosis and chronic pain.

The Tribunal found that the applicant failed to establish that her pre-existing condition was documented prior to the accident or would prevent maximal recovery within the MIG limit.

The Tribunal also found insufficient evidence of chronic pain.

The application was dismissed.

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

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

The applicant argued that her chronic pain condition took her outside the MIG and that the respondent had conceded the MIG limits by previously paying benefits in excess of the cap due to an administrative error.

The Tribunal found that the administrative error did not remove the applicant from the MIG.

Furthermore, the Tribunal rejected the applicant's chronic pain evidence as unpersuasive due to unexplained gaps in treatment and a lack of supporting medical documentation.

The Tribunal concluded that the applicant's injuries were predominantly minor, dismissed the claim for benefits, and denied the request for an award for unreasonable delay.

The applicant was injured in a rear-end motor vehicle collision and sought statutory accident benefits from the respondent insurer.

The insurer initially denied the benefits on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG), but later conceded the injuries were outside the MIG.

The Tribunal found that the disputed treatment plans for assistive devices, chiropractic treatment, and a functional abilities evaluation were reasonable and necessary to manage the applicant's ongoing pain and assist her in her self-employment.

The Tribunal ordered the insurer to pay the disputed benefits with interest, but declined to order a special award as the insurer's delay did not prejudice the applicant.

The respondent insurer requested reconsideration of a Tribunal order denying its request for the applicant to produce clinical notes and records from 29 doctors seen post-accident.

The Tribunal originally denied the request on the basis of proportionality, assuming most records would be in the hospital file.

On reconsideration, the Tribunal granted the request, noting that relevance was undisputed and that 18 of the 29 physicians' records were not included in the hospital file.

The applicant was ordered to produce the records of those 18 physicians, with the respondent undertaking to pay the associated invoices.

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

The respondent denied claims for a psychological assessment and treatment, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found that the respondent failed to comply with the notice requirements under s. 38(8) of the Schedule because its Explanation of Benefits did not provide valid medical reasons for denying the psychological assessment.

Consequently, the applicant was removed from the MIG, and the cost of the assessment was payable.

The Tribunal also found the psychological treatment plan reasonable and necessary, as the respondent provided no competing psychological evidence.

The claim for an award under Regulation 664 was dismissed, but interest was awarded on the overdue benefits.

The insured requested a reconsideration of a Tribunal decision that ordered her to repay $17,200 in overpaid income replacement benefits (IRBs) to Unifund.

The insured argued that the Tribunal erred by failing to adjudicate her claim that she was entitled to further IRBs, which should be set off against the overpayment.

The Associate Chair granted the reconsideration in part, finding that the Tribunal made a significant error of law by not considering the insured's arguments and evidence regarding IRB entitlement and set off, which were properly raised in the proceeding.

The matter was remitted back to the Tribunal to determine the issue of IRB entitlement and any resulting set off.

The applicant sought a $10,000 death benefit following her mother's death in a motor vehicle accident, claiming she was principally dependent on her mother for financial support and care.

The Licence Appeal Tribunal found that the applicant, who was employed and earning over $44,000 annually, was capable of meeting her own financial needs and was not financially dependent on her mother.

The application for the death benefit and associated interest was dismissed.

The applicant sought statutory accident benefits following two motor vehicle accidents.

The insurer denied various treatment plans for chiropractic and massage therapy, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The applicant argued for removal from the MIG based on a pre-existing condition and chronic pain.

The Tribunal found no compelling evidence of a pre-existing condition that would prevent maximal recovery within the MIG limits.

Furthermore, surveillance and employment evidence contradicted the applicant's claim of chronic pain, showing he worked 12-hour shifts and engaged in physical activities without apparent discomfort.

The Tribunal concluded the injuries were predominantly minor and dismissed the application.

The applicant withdrew their application for statutory accident benefits on the morning of the scheduled hearing.

The respondent subsequently brought a motion for costs of $3,000, arguing the applicant's conduct was unreasonable.

The Tribunal found it had jurisdiction to hear the costs motion despite the withdrawal, as the respondent had previously given notice of its intent to seek costs.

However, the Tribunal dismissed the motion, finding that while the applicant's conduct may have lacked professionalism, it did not meet the high threshold of being unreasonable, frivolous, vexatious, or in bad faith, and the respondent suffered no prejudice.

The applicant sought non-earner benefits following a motor vehicle accident.

The respondent denied the benefits based on insurer's examinations which concluded the applicant did not suffer a complete inability to carry on a normal life.

The Tribunal preferred the detailed reports of the respondent's assessors over the brief letter from the applicant's family physician.

The Tribunal found the applicant was able to continue his pre-accident activities and dismissed the claim for non-earner benefits, interest, and costs.

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

The insurer denied further medical benefits and a non-earner benefit, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) and that he did not suffer a complete inability to carry on a normal life.

The Tribunal found that the applicant's psychological impairments took him outside the MIG, entitling him to most of the disputed treatment plans.

However, the Tribunal dismissed the claim for the non-earner benefit, finding surveillance and medical evidence showed the applicant was not continuously prevented from engaging in substantially all of his pre-accident activities.

Claims for costs and a special award were also dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident, specifically claiming $1,765.20 for a chronic pain assessment.

The respondent insurer denied the claim based on a paper review by a physiatrist who opined that further psychological treatment alone was sufficient.

The Tribunal found the applicant's evidence, including assessments from treating practitioners and a chronic pain assessment report, to be more persuasive than the insurer's paper review.

The Tribunal held that the chronic pain assessment was reasonable and necessary, and awarded the cost of the examination along with interest on the overdue payment.

The respondent's procedural defence regarding an unsigned treatment plan was dismissed as the insurer had waived the requirement by scheduling an examination.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for an in-home assessment and chiropractic services.

The insurer denied the treatment plans.

The Licence Appeal Tribunal found that the applicant failed to prove on a balance of probabilities that the proposed treatments were reasonable and necessary.

The medical evidence, including reports from the applicant's own orthopedic surgeons, indicated that the applicant had plateaued and that conservative therapy would not be beneficial.

The application was dismissed.

The respondent insurer brought a preliminary issue motion to stay the applicant's claim for post-104 week attendant care benefits pending the outcome of a FSCO appeal regarding pre-104 week benefits, and to exclude the FSCO arbitration transcripts.

The Tribunal dismissed the motion, finding that the issues before the Tribunal and FSCO were distinct, related to different time periods, and were based on different assessment forms.

The Tribunal also allowed the FSCO transcripts into evidence as prima facie relevant.

The applicant's request for costs was dismissed as there was no evidence of bad faith by the respondent.

The applicant was blinded in one eye when struck by an egg thrown from a passing motor vehicle.

She applied for statutory accident benefits, which the respondent insurer denied on the basis that the incident was not an 'accident' under the Statutory Accident Benefits Schedule.

The Licence Appeal Tribunal found that the incident was an assault, and the throwing of the egg was an independent and intervening act.

The use or operation of the vehicle was not the direct cause of the impairment.

The application was dismissed.

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

The respondent denied the claims on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG), capping medical and rehabilitation benefits at $3,500.

The applicant argued that chronic pain removed him from the MIG.

The Tribunal found that the applicant failed to prove the chronic pain was caused by the accident, noting subsequent injuries and degenerative conditions that were not addressed by the applicant's medical assessors.

The application was dismissed.

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

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

The applicant argued that pre-existing lower back and psychological conditions prevented her from achieving maximal recovery within the MIG limits.

The Tribunal found insufficient evidence of any pre-existing conditions that would warrant removal from the MIG.

Consequently, the applicant's injuries were deemed minor, and her claims for additional medical benefits and examination costs were dismissed.