OLAT 2018

The applicant sought payment for statutory accident benefits following a motor vehicle accident, including attendant care benefits, a non-earner benefit, and the cost of various assessments.

The Licence Appeal Tribunal found the applicant was not entitled to attendant care benefits or a non-earner benefit, as she failed to prove the expenses were reasonable and necessary or that she suffered a complete inability to carry on a normal life.

However, the Tribunal ordered the respondent to pay for a chronic pain assessment and two Assessments of Attendant Care Needs, finding them to be reasonable and necessary expenses, along with applicable interest.

The applicant sought payment for an in-home assessment under the Statutory Accident Benefits Schedule following a motor vehicle accident.

The respondent denied the claim on the basis that the expense was incurred before the treatment plan (OCF-18) was submitted, contrary to section 38(2) of the Schedule.

The applicant brought a motion to preclude the respondent from relying on this defence, arguing it was raised late.

The Adjudicator dismissed the motion, finding no prejudice to the applicant.

On the substantive issue, the Adjudicator found the applicant failed to comply with section 38(2) by incurring the expense prior to submitting the OCF-18, and therefore the cost of the assessment was not payable.

The applicant sought non-earner benefits, attendant care benefits, and the cost of a chronic pain assessment following a motor vehicle accident.

The adjudicator found the applicant was barred from pursuing the chronic pain assessment due to her failure to attend section 44 insurer examinations without a valid reason.

The claims for non-earner and attendant care benefits were dismissed because the applicant failed to establish a complete inability to carry on a normal life or that the attendant care expenses were incurred, with the adjudicator preferring the respondent's medical evidence and noting inconsistencies in the applicant's self-reporting and treating physician's records.

The applicant sought income replacement benefits and funding for a psychological treatment plan following a motor vehicle accident.

The Licence Appeal Tribunal dismissed the application, finding the applicant failed to prove on a balance of probabilities that he suffered a substantial inability to perform the essential tasks of his pre-accident employment as a security guard.

The Tribunal preferred the insurer's psychological assessment, which found no ongoing psychological impairment, and concluded the proposed treatment plan was not reasonable and necessary.

The applicant sought an award under s. 10 of O. Reg. 664, interest on overdue benefits, and costs following a motor vehicle accident.

The respondent had initially denied a treatment plan based on the Minor Injury Guideline (MIG) limits but later removed the applicant from the MIG as a gesture of good faith.

The Tribunal found that the respondent's initial denial was reasonable based on the medical evidence provided and did not constitute unreasonable withholding or delay of benefits.

The applicant was awarded interest on incurred amounts, but claims for a special award and costs were dismissed.

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

The insurer denied the claims, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) and the $3,500 limit had been exhausted.

The applicant argued she sustained psychological impairments that removed her from the MIG.

The adjudicator preferred the insurer's psychological assessment, which included validity testing indicating symptom magnification, over the applicant's psychological evidence.

The adjudicator concluded the applicant's injuries were predominantly minor, dismissing the claims for additional medical benefits, an award for unreasonable delay, and interest.

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

The respondent denied funding for a $2,495.48 physiotherapy treatment plan on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG) and the $3,500 limit was exhausted.

The applicant argued that a pre-existing finger fracture and a psychological injury warranted removal from the MIG.

The Tribunal found insufficient evidence that the pre-existing injury hindered recovery and rejected the psychological assessment report as it contradicted the applicant's medical records.

The application was dismissed, and the applicant was held to the MIG limits.

The applicant sought statutory accident benefits following a motor vehicle accident, including an income replacement benefit and various medical and rehabilitation benefits.

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

The Tribunal found that the applicant's physical injuries were predominantly minor and that he failed to establish a psychological impairment or chronic pain condition that would remove him from the MIG.

The Tribunal preferred the respondent's psychological assessment over the applicant's, noting the latter omitted a significant life event.

The Tribunal also found the applicant failed to prove he missed work as a result of the accident, dismissing the claim for an income replacement benefit.

The application was dismissed in its entirety.

The applicant insurer sought repayment of benefits and claim adjustment costs from the respondent, alleging he wilfully misrepresented being a passenger in an insured vehicle during an accident.

The respondent did not participate in the hearing.

The Tribunal found that the respondent was not an occupant of the vehicle and that his claim was based on a wilful misrepresentation.

The Tribunal ordered the respondent to repay $200.00 in benefits plus interest.

However, the Tribunal held it lacked jurisdiction to order repayment of the insurer's claim adjustment costs, such as insurer's examination fees, and denied the insurer's request for costs of the proceeding.

The applicant sought a medical benefit for a physiotherapy treatment plan in the amount of $1,501.04 following a motor vehicle accident.

The respondent initially denied the benefit but later advised the Tribunal that it had approved the disputed treatment plan.

The adjudicator found that the respondent conceded the claim, resolving the dispute, and noted that the respondent is liable to pay interest on the overdue payment pursuant to s. 51 of the Schedule.

The applicant was injured in a motor vehicle accident and sought a determination of catastrophic impairment.

The respondent insurer requested that the applicant attend section 44 multidisciplinary examinations.

The applicant refused to attend, arguing the requests were unreasonable and untimely.

The Tribunal applied the six-factor test for reasonableness and found the insurer's requests were reasonable and timely, as they were made after the two-year anniversary of the accident to assess specific criteria.

The Tribunal ordered that the applicant is barred from proceeding with his application until he attends the requested physiatry, psychology, and otolaryngology examinations, and directed the insurer to schedule them within 35 days.

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

The respondent denied the benefits on February 15, 2011.

The applicant filed an application with the Licence Appeal Tribunal over six years later.

The applicant argued the limitation period had not run because the respondent failed to request a new disability certificate prior to scheduling assessments, and because the denial was not clear and unequivocal.

The Tribunal found that the denial was clear and unequivocal, and that the failure to request a new disability certificate did not warrant extending the limitation period.

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

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

The respondent insurer raised preliminary issues, arguing that several of the applicant's claims were statute-barred because she failed to appeal within the two-year limitation period, and that other claims were barred because she failed to submit them within the prescribed timelines.

The Tribunal found that the insurer's explanation of benefits for the attendant care and certain medical benefits did not constitute a clear and unequivocal denial, meaning the limitation period was not triggered and those claims could proceed.

However, the Tribunal found that the denial for the cost of examinations was clear and unequivocal, barring that claim.

The Tribunal also held that the applicant lacked a reasonable explanation for her late submission of transportation claims, barring those from proceeding.

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

The insurer denied funding for additional chiropractic treatments and assessments beyond the $3,500 Minor Injury Guideline (MIG) limit.

The Licence Appeal Tribunal found that the applicant's physical and psychological injuries fell within the MIG.

The Tribunal preferred the evidence of the insurer's medical experts, who provided extensive reports based on testing, over the applicant's practitioners, who failed to provide details of testing or lacked appropriate accreditation.

As the applicant had already exhausted the MIG funding limit, the claims for additional medical benefits and interest were dismissed.

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

The respondent insurer brought a preliminary motion to bar the application because the applicant failed to attend independent medical examinations (IEs) under s. 44 of the Schedule and failed to provide requested information under s. 33.

The Tribunal found the applicant was barred from proceeding with his appeal for medical benefits and examination costs due to his unexcused failure to attend the IEs.

However, the insurer was liable to pay non-earner benefits for a specific period due to its failure to provide proper notice of election of benefits, though it could withhold payments for the subsequent period of the applicant's non-compliance with s. 33.

The respondent insurer requested a reconsideration of a decision finding the applicant sustained a catastrophic impairment and was entitled to attendant care benefits (ACBs) for services provided by his spouse.

The insurer argued the adjudicator erred by admitting opinion evidence on causation from a treating chiropractor who was not qualified as an expert, and by awarding ACBs for care provided by a family member.

The Associate Chair denied the reconsideration, holding that the chiropractor's evidence was admissible as a 'participant expert' under Westerhof, and that the spouse, a trained personal support worker and registered practical nurse, provided the attendant care services in the course of her profession.

The adjudicator's findings that the applicant promised to pay his spouse and required overnight supervision were reasonable and did not constitute significant errors of law or fact.

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

The respondent insurer deemed the injuries to fall within the Minor Injury Guideline (MIG) and denied a $2,200 psychological assessment.

The applicant applied to the Licence Appeal Tribunal.

The Tribunal found that the applicant's psychological impairments, including adjustment disorder and somatic symptom disorder, fell outside the definition of a minor injury.

The Tribunal preferred the evidence of the applicant's psychologist over the insurer's assessor, noting the insurer's assessor discounted moderate impairment test results without reasonable explanation.

The Tribunal ordered the respondent to pay for the psychological assessment with interest, but declined to order an award for unreasonably withheld payments.

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

The respondent insurer denied the treatment plans based on insurer examinations which found no objective physical impairments and concluded that the applicant's psychological symptoms were related to pre-existing behavioural issues rather than the accident.

The adjudicator agreed with the respondent's medical experts, finding that the applicant failed to prove the treatments were reasonable and necessary.

The application was dismissed.

The applicant sought to set aside a settlement agreement regarding statutory accident benefits, arguing he lacked mental capacity and was under duress when he signed it.

The Licence Appeal Tribunal found that the applicant failed to rescind the settlement within the two-day cooling period required by O. Reg. 664.

The Tribunal held that the applicant did not establish on a balance of probabilities that he lacked capacity or was under duress at the time of settlement.

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

The applicant sought statutory accident benefits following a motor vehicle accident, claiming her injuries fell outside the Minor Injury Guideline (MIG) due to chronic pain, fibromyalgia, depression, and PTSD.

The Tribunal found the applicant's injuries were predominantly minor, noting a lack of objective medical evidence and rejecting expert opinions that were outside their scope of expertise or unsupported by evidence.

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

Consequently, the applicant was subject to the $3,500 MIG limit and was not entitled to the disputed costs of examinations or interest.