OLAT 2018

The applicant sought medical and rehabilitation benefits under the Statutory Accident Benefits Schedule following a motor vehicle accident.

The adjudicator found the applicant was entitled to $1,070 for assistive devices, as they were reasonable and necessary to treat accident-related pain, despite the applicant's concurrent pregnancy.

Claims for a cast and crutches were dismissed as abandoned, and a claim for chiropractic services was dismissed because the applicant had several unexhausted approved treatment plans for similar physical therapies.

Interest was awarded on the overdue payment for the assistive devices.

The applicant sought dispute resolution for various denied statutory accident benefits following a motor vehicle accident, including attendant care, medical benefits, and out-of-pocket expenses.

The Licence Appeal Tribunal found the applicant was entitled to $297.00 for attendant care provided by a qualified personal support worker.

The Tribunal also awarded $200.00 for the completion of an OCF-18 and $360.00 for a psychological progress report, finding the respondent's denials unreasonable.

The remaining claims for treatment plans, assistive devices, and transportation expenses were dismissed for lack of evidence or failure to meet statutory requirements.

Interest was awarded on the overdue amounts.

The applicant was involved in a motor vehicle accident in 2005.

The respondent insurer denied attendant care benefits in April 2005 based on an occupational therapy assessment, even though the applicant had not expressly claimed them.

In 2015, after being deemed catastrophically impaired, the applicant applied for attendant care benefits.

The respondent denied the claim, arguing it was barred by the two-year limitation period triggered by the 2005 denial.

The Tribunal found that the 2005 denial was clear and unequivocal, and following the Court of Appeal's decision in Sietzema, a premature denial is sufficient to trigger the limitation period.

The applicant's claim was therefore statute-barred.

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

The respondent denied claims for medication expenses and a facility-based exercise program, arguing the applicant's conditions were pre-existing.

The Tribunal found that the accident caused an aggravation of the applicant's pre-existing conditions.

The Tribunal allowed the claim for medication expenses, including medical marijuana, finding them reasonable and necessary.

However, the Tribunal dismissed the claim for the facility-based exercise program, accepting the respondent's insurer's examination report that the exercises could be done at home.

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

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

Procedurally, the Tribunal excluded surveillance evidence submitted late by the respondent in breach of a prior order, awarding $300 in costs to the applicant.

Substantively, the Tribunal found that the applicant failed to provide compelling evidence of a pre-existing condition that would prevent maximal recovery within the MIG limits.

Consequently, the applicant's claims for medical and rehabilitation benefits beyond the $3,500 cap were dismissed.

The applicant sought a determination that she sustained a catastrophic impairment due to a mental or behavioural disorder following a motor vehicle accident.

The Tribunal applied the AMA Guides and the three-step test from Pastore.

While finding the applicant suffered a psychological impairment caused by the accident, the Tribunal concluded she did not suffer a marked (Class 4) impairment in any of the four functional domains.

The Tribunal preferred the respondent's multidisciplinary medical evidence over the applicant's experts, noting credibility concerns and the applicant's failure on performance validity tests.

The application was dismissed.

The applicant was injured in a motor vehicle accident and sought income replacement benefits (IRBs) and the cost of a psychological assessment.

The adjudicator found that the applicant failed to prove that her inability to work was caused by the accident, noting significant pre-accident and post-accident medical issues unrelated to the collision.

The adjudicator accepted the respondent's medical assessments that the applicant could perform the essential tasks of her pre-accident employment.

While the adjudicator found the psychological assessment was necessary, the claim was dismissed because the applicant failed to prove the proposed fees were reasonable under the Professional Services Guideline.

The application was dismissed.

The applicant sought a medical benefit of $4,124.88 for chiropractic services following a motor vehicle accident.

The respondent insurer initially denied the benefit under the Minor Injury Guideline, but later conceded the applicant was removed from the guideline based on a psychological assessment.

The adjudicator found that the applicant failed to provide objective medical evidence to prove the chiropractic treatment was reasonable and necessary, noting that her own treating physicians recommended physiotherapy rather than chiropractic care.

The application was dismissed, and the applicant's request for costs based on the insurer's alleged bad faith was denied.

The applicant sought interest on overdue income replacement benefits (IRBs), a rehabilitation benefit for an orthopedic mattress, and a special award following a motor vehicle accident.

The Tribunal found that the applicant was entitled to interest on the IRBs because the respondent conceded the benefits were payable, making them overdue under s. 51 of the Schedule.

The claim for the orthopedic mattress was dismissed as the applicant failed to prove it was reasonable and necessary, with both parties' physiatrists indicating it would not significantly assist with pain management.

The claims for costs and a special award were also dismissed as there was no evidence of bad faith or unreasonable delay by the respondent.

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

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

The Tribunal found that the applicant failed to prove her injuries fell outside the MIG or that she had a pre-existing condition preventing maximal recovery within the MIG limit.

The Tribunal also found the proposed treatment plans were not reasonable and necessary.

The application was dismissed.

The applicant was injured in a motor vehicle accident and sought payment for two orthopaedic assessments under the Statutory Accident Benefits Schedule.

The insurer denied the treatment plans.

The Licence Appeal Tribunal found that the applicant failed to prove the assessments were reasonable and necessary, noting the absence of the actual treatment plans in evidence and preferring the insurer's medical evidence that the applicant suffered only soft tissue injuries.

The appeal was dismissed.

The applicant sought statutory accident benefits for two dental treatment plans related to temporomandibular joint pain following a motor vehicle accident.

The respondent denied the plans based on an insurer's examination which concluded further treatment was unlikely to be beneficial.

The adjudicator dismissed the application, finding the treatment plans were not reasonable and necessary because the applicant failed to provide any supporting medical evidence to contradict the respondent's expert.

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

The respondent denied a treatment plan for chiropractic services, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) and the $3,500 funding limit was exhausted.

The applicant argued the respondent failed to respond to the treatment plan in time and that pre-existing conditions precluded recovery within the MIG.

The Tribunal found the respondent replied within the required timeframe and the applicant failed to prove pre-existing conditions would impede recovery within the MIG.

The Tribunal concluded the injuries were minor, the funding limit was exhausted, and the proposed treatment was not proven reasonable and necessary.

The application was dismissed.

The applicant sought payment for a general practitioner's assessment and psychological services following a motor vehicle accident.

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

The Tribunal found that the applicant failed to prove she suffered from a psychological impairment or chronic pain syndrome that would remove her from the MIG.

The Tribunal preferred the insurer's expert evidence, which included psychometric testing, over the applicant's evidence.

The claims for the assessment, psychological services, and interest were dismissed.

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

The respondent denied a treatment plan for chiropractic services, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found that the applicant's injuries fell outside the MIG because the accident aggravated pre-existing injuries and materially contributed to the development of chronic pain syndrome.

However, the Tribunal dismissed the claim for the specific treatment plan, finding the applicant failed to prove it was reasonable and necessary given her lack of progress with similar past treatments.

The applicant sought statutory accident benefits following a motor vehicle accident, including ongoing non-earner benefits and two physiotherapy treatment plans.

The insurer had paid non-earner benefits for six months but sought to retroactively terminate them, while also denying the treatment plans.

The Licence Appeal Tribunal found that the applicant did not meet the test for ongoing non-earner benefits after November 2015, given her level of post-accident activity, but refused to retroactively terminate the benefits already paid.

The Tribunal granted the two physiotherapy treatment plans, finding them reasonable and necessary due to the close connection between the applicant's physical pain and her psychological conditions, including post-traumatic stress disorder and depression.

The applicant sought income replacement benefits (IRBs) and attendant care benefits (ACBs) following a motor vehicle accident.

The Tribunal found the applicant lacked credibility, having concealed her return to work and regular gym attendance from assessors.

Relying on objective medical imaging and the respondent's experts, the Tribunal concluded the applicant did not suffer a substantial inability to perform the essential tasks of her pre-accident employment as a dental assistant.

The claim for ACBs was dismissed because the expenses were not incurred as defined in the Schedule.

The respondent was awarded repayment of $2,984.59 for IRBs paid while the applicant was working.

Both parties' requests for costs were denied.

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

The respondent insurer argued the applicant was precluded from proceeding before the Licence Appeal Tribunal under section 55 of the Statutory Accident Benefits Schedule for allegedly failing to attend insurer examinations under section 44.

The adjudicator found insufficient evidence that the respondent made reasonable efforts to schedule convenient appointments or that the applicant refused to attend relevant examinations.

The applicant was permitted to proceed with the application.

The applicant was injured in a motor vehicle accident and sought funding for a psychological assessment under the Statutory Accident Benefits Schedule.

The respondent insurer denied the treatment plan based on an insurer's examination report which suggested the applicant was amplifying symptoms.

The Tribunal found the applicant's evidence, including consistent self-reported symptoms and prescriptions for antidepressants from family physicians, more compelling than the insurer's examination.

The Tribunal ordered the respondent to pay $1,995.33 for the psychological assessment and interest on overdue amounts.