OLAT 2019

The applicant sought statutory accident benefits following a motor vehicle accident, claiming entitlement to a physiatry assessment, assistive devices, and physiotherapy.

The respondent insurer denied the benefits, relying on insurer's examinations which concluded the applicant had reached maximum medical recovery from minor soft tissue injuries.

The adjudicator found that the applicant failed to prove the claimed benefits were reasonable and necessary, preferring the detailed analysis of the insurer's experts over the applicant's medical evidence.

The appeal was dismissed and no benefits or interest were awarded.

The applicant sought a medical benefit of $2,200 for psychological services following a motor vehicle accident.

The respondent denied the claim, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) limit of $3,500, which had already been largely exhausted.

The Tribunal found that the applicant's physical injuries were soft tissue in nature and that the psychological evidence provided was insufficient to remove him from the MIG.

The Tribunal dismissed the claim for benefits and interest, and also denied the respondent's request for costs, finding no bad faith on the part of the applicant.

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

The insurer denied several treatment plans and non-earner benefits on the basis that the injuries fell within the Minor Injury Guideline (MIG) and requested section 44 insurer's examinations (IEs).

The applicant refused to attend the IEs, arguing that an insurer cannot compel an IE specifically to determine the applicability of the MIG.

The Tribunal held that determining whether an impairment falls within the MIG is a prerequisite to assessing whether treatment plans are reasonable and necessary, and that section 38(10) permits an insurer to request an IE when it believes the MIG applies.

Because the applicant failed to attend properly scheduled IEs without a reasonable excuse, she is statute-barred from proceeding with her application under section 55(1)2 of the Schedule.

The applicant was injured in a rear-end motor vehicle accident and sought Non-Earner Benefits (NEB) under the Statutory Accident Benefits Schedule.

The respondent denied the NEB, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) and she did not suffer a complete inability to carry on a normal life.

The Tribunal found that the applicant's injuries were predominantly soft tissue injuries falling within the MIG.

Relying on Independent Medical Examinations and the applicant's family physician's clinical notes, the Tribunal concluded the applicant failed to meet the burden of proving a complete inability to carry on a normal life.

The application for NEB and interest was dismissed.

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

The insurer denied the benefits on July 20, 2015.

The applicant filed a dispute with the Licence Appeal Tribunal on February 14, 2018, beyond the two-year limitation period under section 56 of the Statutory Accident Benefits Schedule.

The applicant argued the limitation period should start from a later date based on discoverability, but the Tribunal held the Limitations Act does not apply to its proceedings.

The Tribunal found the denial was clear and unequivocal, and declined to extend the time to file the dispute under section 7 of the Licence Appeal Tribunal Act, citing prejudice to the insurer and lack of explanation for the delay.

The application for these benefits was dismissed as statute-barred.

The applicant was injured in a bicycle-motorcycle collision and sought various statutory accident benefits, including a determination of catastrophic impairment (CAT).

The Licence Appeal Tribunal found that the applicant sustained a catastrophic impairment due to a marked impairment in the adaptation domain resulting from psychological and behavioural disorders.

However, the Tribunal dismissed the applicant's claims for post-104 week income replacement benefits, finding he did not suffer a complete inability to work.

Claims for attendant care and housekeeping benefits were also dismissed because the applicant failed to prove his father, the service provider, suffered an economic loss.

A claim for a special award was denied as the insurer did not unreasonably withhold benefits.

The applicant sought medical benefits for two physiotherapy treatment plans and the cost of an attendant care assessment following a motor vehicle accident.

The respondent insurer denied the claims on the basis that they were not reasonable and necessary, relying on independent medical examinations which concluded the applicant had reached maximum medical recovery from soft tissue injuries.

The adjudicator dismissed the application, preferring the evidence of the insurer's assessors who conducted physical examinations over the applicant's occupational therapy paper review report.

The adjudicator found the applicant had returned to full-time work, was independent in personal care, and did not require further treatment.

The applicant sought medical and rehabilitation benefits following a motor vehicle accident.

The respondent denied the benefits on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG) and the $3,500 limit had been exhausted.

The applicant argued she was exempt from the MIG due to chronic pain and a pre-existing condition of sciatica.

The Tribunal found insufficient evidence of chronic pain and concluded that the applicant failed to prove her pre-existing sciatica prevented her from achieving maximal recovery within the minor injury limits.

The application for benefits, interest, and a special award was dismissed.

The applicant was injured in a rear-end motor vehicle accident and sought medical benefits under the Statutory Accident Benefits Schedule.

The respondent denied the benefits on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG) and the $3,500 funding limit had been exhausted.

The applicant argued that diagnoses of a rotator cuff injury, chronic pain syndrome, and psychological injuries removed them from the MIG.

The Tribunal found that the applicant suffered predominantly minor soft tissue injuries and that the medical evidence did not support a diagnosis of chronic pain syndrome or a psychological injury.

As the applicant had 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, claiming entitlement to income replacement benefits (IRBs), medical benefits for physiotherapy, and the cost of attendant care assessments.

The Licence Appeal Tribunal dismissed the claim for IRBs, finding no evidence of a substantial inability to perform the essential tasks of employment.

The Tribunal granted the cost of the initial physiotherapy treatment plan incurred during the acute phase of recovery, but denied subsequent plans as the applicant had reached maximum medical recovery from minor soft tissue injuries.

The Tribunal also awarded the cost of a single attendant care assessment, rejecting a retroactive assessment as meaningless and duplicative.

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

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

The Licence Appeal Tribunal found that the applicant's injuries were predominantly soft tissue injuries subject to the MIG, and that he failed to establish any pre-existing condition that would impede his recovery.

The Tribunal also dismissed the applicant's claims for non-earner benefits, finding no evidence of a complete inability to carry on a normal life, as well as claims for physiotherapy, emergency services expenses, and a special award.

The applicant sought a medical benefit of $2,004.96 for a chiropractic treatment plan following a motor vehicle accident.

The respondent insurer denied the claim based on a section 44 assessment by a chiropractor who concluded the applicant no longer suffered from an accident-related impairment.

The Licence Appeal Tribunal dismissed the application, finding that the impairments listed in the treatment plan were unsupported by medical evidence and that the uncontradicted opinion of the respondent's assessor was persuasive.

The Tribunal concluded the treatment plan was not reasonable and necessary.

The applicant sought statutory accident benefits following a motor vehicle accident, including income replacement benefits (IRBs), removal from the Minor Injury Guideline (MIG), and various medical and rehabilitation benefits.

The Tribunal found the applicant was not entitled to IRBs because he had quit his job prior to the accident and did not qualify for Employment Insurance due to misreporting income.

The Tribunal removed the applicant from the MIG based on psychological impairments identified by both the applicant's and respondent's assessors.

However, the Tribunal denied the claims for chiropractic, massage, and acupuncture treatment, as well as an x-ray, finding them not reasonable and necessary or barred by timing rules.

The claim for a psychological assessment was granted.

The respondent insurer requested reconsideration of a motion order that dismissed its request to remove five treatment plans from the applicant's application.

The insurer argued the applicant had exhausted the $50,000 non-catastrophic limit and had not yet been determined to be catastrophically impaired.

The Vice Chair dismissed the reconsideration request, finding no significant error of law.

On her own initiative, the Vice Chair reconsidered the Tribunal's previous denial of an adjournment, ordering that the upcoming hearing be adjourned and the applicant's two files be combined to allow the catastrophic impairment issue to be determined first.

The applicant sought statutory accident benefits for a Functional Abilities Evaluation (FAE), vocational assessments, and a Chronic Pain Assessment (CPA) following a motor vehicle accident.

The adjudicator found the FAE and vocational assessments were reasonable and necessary to determine the applicant's capacity to work as a drywaller and painter, awarding the prescribed maximum of $4,400.00 plus interest.

However, the claim for a CPA was denied because the applicant already had a comprehensive chronic pain diagnosis and the proposed assessment would not provide new medical guidance.

The respondent's request for costs was dismissed.

The applicant sought a medical and rehabilitation benefit of $2,661.57 for physiotherapy following a motor vehicle accident, along with interest and an award for unreasonable delay.

The Licence Appeal Tribunal dismissed the application, finding that the applicant failed to provide any medical evidence or argument to prove the treatment was reasonable and necessary.

The insurer's examination concluded the treatment was not required, and the applicant's criticisms of the insurer's claims adjustment process did not substitute for positive medical evidence.

Consequently, the claims for interest and an award were also dismissed.

The applicant, who was catastrophically impaired following a motor vehicle accident, sought funding for home accessibility and alternative housing assessments.

The insurer partially approved the first assessment up to the $2,000 limit and denied the second as a duplication.

The Licence Appeal Tribunal held that both assessments are subject to the $2,000 cap under section 25(5)(a) of the 2010 Statutory Accident Benefits Schedule, as they constitute clinical evaluations or appraisals of the applicant's health status.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits, including income replacement and medical benefits.

The respondent denied the benefits, arguing the applicant did not meet the requisite disability tests and the treatments were not reasonable and necessary.

The Tribunal found the applicant suffered a substantial inability to perform the essential tasks of her pre-accident employment for the first 104 weeks, entitling her to income replacement benefits for the disputed period up to the 104-week mark.

However, the applicant failed to prove a complete inability to engage in any suitable employment thereafter.

The Tribunal also found the disputed physiotherapy and psychological treatment plans to be reasonable and necessary, ordering their payment with interest.

The applicant sought statutory accident benefits for chiropractic and physiotherapy treatments following a 2013 motor vehicle accident.

The Licence Appeal Tribunal dismissed the application, finding that the applicant failed to establish that the claimed expenses were reasonable and necessary as a result of the accident.

The Tribunal noted a significant gap of two to three years between the accident and the medical records provided, which prevented the establishment of a causal link.

A new issue raised at the hearing for additional chiropractic expenses was permitted but denied because no treatment plan had been submitted.

The applicant insurer sought repayment of $2,193.57 in non-earner benefits paid to the respondent, arguing it had mistakenly applied a 4-week waiting period instead of the applicable 26-week waiting period.

The respondent argued the insurer's notice of repayment was out of time under s. 52(3) of the Statutory Accident Benefits Schedule, as it was sent more than 12 months after the first erroneous payment.

The Tribunal agreed with the respondent, finding that the 12-month limitation period commences from the first payment made in error, rejecting the insurer's argument for a 'rolling limitation period.' The application for repayment was dismissed, and the respondent's request for costs was also denied.