OLAT 2020

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

The respondent insurer denied a treatment plan for a chronic pain assessment, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The applicant argued she should be removed from the MIG due to pre-existing conditions and chronic pain.

The Tribunal found that the applicant's pre-existing conditions did not preclude her from achieving maximal medical recovery within the MIG limit.

Applying the AMA Guides criteria for chronic pain, the Tribunal concluded the applicant failed to establish that she suffered from chronic pain caused by the accident.

The application was dismissed, and the applicant was not entitled to the treatment plan or interest.

The applicant sought statutory accident benefits following a 2014 motor vehicle accident.

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

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

The Tribunal found the applicant sustained predominantly minor soft tissue injuries and failed to prove chronic pain or that her pre-existing depression precluded recovery within the MIG limits.

The Tribunal also denied the cost of an accounting report, finding it was not reasonable and necessary as the applicant's income calculation was straightforward.

The application was dismissed.

The applicant was injured in a motor vehicle accident and sought non-earner benefits (NEBs) from the respondent insurer.

The respondent denied the claim, arguing the applicant was statute-barred for failing to submit a 'completed' OCF-3 Disability Certificate, as the submitted form indicated she did not suffer a complete inability to carry on a normal life.

The Tribunal found the OCF-3 was complete and the applicant was not statute-barred.

However, on the substantive issue, the Tribunal compared the applicant's pre- and post-accident activities and found she failed to prove a complete inability to carry on a normal life, noting significant pre-existing physical and psychological limitations.

The claims for NEBs, an award, interest, and costs were dismissed.

The applicant was injured in a motor vehicle accident in December 2018 but did not apply for statutory accident benefits until December 2019.

The respondent insurer brought a motion to dismiss the application on the basis that the applicant failed to notify it of her intention to apply within seven days, as required by section 32(1) of the Statutory Accident Benefits Schedule.

The Tribunal found that the applicant failed to provide a reasonable explanation for the delay under section 34, noting that ignorance of the law and a subjective belief that injuries would improve are not reasonable excuses.

The Tribunal concluded that the respondent was prejudiced by the delay and dismissed the application as statute-barred under section 55(1).

The applicant sought an order for the production of unredacted adjusting log notes and to add a claim for punitive damages to the hearing.

The applicant argued that the respondent's co-mingling of tort and accident benefits files resulted in an unfair litigation advantage and waived privilege.

The Tribunal denied the request for unredacted notes, finding no unfair advantage as the respondent had replaced both counsel and the adjuster and restricted access to the tort file.

The Tribunal also denied the request to add a claim for punitive damages, confirming it lacks jurisdiction to award punitive damages or damages based on bad faith.

The applicant sought interest and a special award under Regulation 664, alleging that the respondent unreasonably delayed the payment of a $6,000 funeral benefit following the death of her son in a motor vehicle accident.

The respondent argued that the 30-day timeline for payment did not commence until the applicant provided confirmation that no WSIB claim had been filed, as the accident occurred during the course of employment.

The Tribunal found that the application was not complete until the WSIB confirmation was received, and the respondent paid the benefit within 30 days of that date.

The claims for interest and a special award were dismissed.

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

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

The applicant argued for removal from the MIG based on a full thickness shoulder tear, a pre-existing shoulder condition, a psychological injury, and chronic pain.

The Tribunal found that the applicant failed to prove the shoulder tear was caused by the accident, failed to show the pre-existing condition prevented maximal recovery within the MIG limits, and failed to establish a psychological impairment or chronic pain.

Consequently, the applicant's injuries were deemed predominantly minor, and the claims for treatment outside the MIG limits were dismissed.

The applicant sought statutory accident benefits following a 2018 motor vehicle accident.

The respondent insurer denied funding for chiropractic treatment, the unapproved balance of a psychological treatment plan, and an orthopedic assessment.

The Licence Appeal Tribunal found that the applicant's ongoing pain complaints and functional impairments, supported by medical records and an orthopedic assessment diagnosing chronic pain syndrome, justified the disputed treatment plans.

The Tribunal ordered the respondent to pay the full amounts for the chiropractic treatment and orthopedic assessment, a partial amount for the psychological treatment plan, and interest on overdue payments.

The applicant was injured in a motor vehicle accident and sought medical benefits for chiropractic, physiotherapy, and psychological assessments.

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 were not predominantly minor.

The medical evidence did not support a diagnosis of chronic pain or a psychological impairment that would warrant removal from the MIG.

As the injuries were within the MIG, the Tribunal did not need to determine the reasonableness and necessity of the treatment plans, and no interest was payable.

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

The respondent insurer took the position that the applicant's injuries fell within the Minor Injury Guideline (MIG) and denied several treatment plans.

The applicant argued she should be removed from the MIG due to pre-existing conditions and chronic pain.

The Tribunal found the applicant failed to prove that her pre-existing conditions prevented maximal recovery within the MIG or that her chronic pain adversely affected her well-being and function under the AMA Guides criteria.

However, the Tribunal ordered the respondent to pay for a physiatry assessment because the respondent failed to provide proper medical reasons for its denial, triggering the consequences of s. 38(11) of the Schedule.

The remaining treatment plans were dismissed as they proposed treatment outside the MIG limits.

The applicant sought income replacement benefits (IRBs) and payment for an accounting report following a motor vehicle accident.

The Tribunal found the applicant was not entitled to IRBs within 104 weeks of the accident, as surveillance evidence and an Employer's Confirmation Form showed he had returned to his pre-accident employment as a contractor.

The applicant also failed to meet the stricter post-104-week test.

The claim for the accounting report was denied because it incorrectly calculated the IRB amount and was not reasonable or necessary.

The application was dismissed.

The applicant sought income replacement benefits (IRBs) and payment for an accounting report following a motor vehicle accident.

The Licence Appeal Tribunal dismissed the application, finding the applicant failed to prove on a balance of probabilities that she suffered a substantial inability to perform the essential tasks of her pre-accident employment within 104 weeks of the accident, or that she was completely unable to engage in any employment for which she was reasonably suited thereafter.

The claim for the accounting report was also dismissed as it incorrectly calculated the IRB amount and was not reasonable and necessary.

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

The parties verbally agreed to settle the claims for $12,000 at a case conference.

The respondent sent the settlement documents directly to the applicant, who signed them despite having legal representation.

The applicant later disputed the validity of the settlement agreement, arguing it was void ab initio because the respondent dealt with her directly, and alternatively, that it should be set aside due to a mistake in communication with her husband.

The Tribunal found that the respondent complied with the disclosure requirements under O. Reg. 664 and that the settlement was not improperly entered into.

The Tribunal also found insufficient evidence to establish a mistake that would warrant setting aside the agreement.

The application was dismissed.

The applicant sought statutory accident benefits for physiotherapy and chiropractic treatment following a 2015 motor vehicle accident.

The respondent denied the treatment plans.

The Licence Appeal Tribunal found that the applicant failed to prove the May 8, 2018 treatment plan was reasonable and necessary due to a lack of compelling contemporaneous medical evidence.

However, the Tribunal awarded $800 for eight sessions of physiotherapy under the January 17, 2019 treatment plan, as it was supported by recommendations from the applicant's family physician and a chronic pain clinic.

The remainder of the 2019 treatment plan was denied.

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

The respondent insurer denied certain benefits, asserting the applicant's injuries fell within the Minor Injury Guideline (MIG), and requested the applicant attend insurer's examinations (IEs) under s. 44 of the Schedule.

The applicant refused to attend, arguing that the Schedule does not permit an IE to determine the applicability of the MIG.

The respondent requested a preliminary issue hearing to determine if the application was barred under s. 55.

The Tribunal found that the applicant's interpretation of the Schedule was incorrect and that she was required to attend the IEs.

Because the applicant failed to attend the IEs without a reasonable explanation, she was barred from proceeding with her application.

The applicant sought income replacement benefits (IRBs) following a motor vehicle accident while she was on maternity leave.

The Tribunal found that the applicant failed to prove on a balance of probabilities that she suffered a substantial inability to perform the essential tasks of her pre-accident employment within 104 weeks of the accident.

Furthermore, the Tribunal drew an adverse inference due to a gap in medical evidence and the occurrence of a second motor vehicle accident, concluding the applicant failed to establish causation.

The claim for IRBs beyond 104 weeks was also dismissed due to insufficient evidence regarding the applicant's education, training, and experience.

The application was dismissed.

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

The respondent insurer determined the applicant's injuries fell within the Minor Injury Guideline (MIG) and its $3,500 funding limit.

The applicant argued that pre-existing shoulder and psychological issues, along with accident-related chronic pain and psychological impairment, removed him from the MIG.

The Tribunal found insufficient medical evidence to support the applicant's claims, noting inconsistencies between the applicant's self-reports, his family physician's records, and the insurer's examinations.

The Tribunal concluded the injuries were predominantly minor and subject to the MIG limit, which the respondent had already substantially paid.

The disputed treatment plans were therefore not payable.

The applicant sought a special award under s. 10 of Regulation 664, alleging the respondent unreasonably delayed payment of an income replacement benefit previously ordered by the Tribunal.

The respondent had attempted to send the payment multiple times but repeatedly mailed it to incorrect addresses due to administrative errors.

The Tribunal found that while the respondent's actions indicated a lack of competence, they did not rise to the level of unreasonableness required for a special award.

The request for an award was dismissed, but the applicant was granted interest on the overdue payment pursuant to s. 51 of the Schedule.

The applicant sought entitlement to the costs of three examinations (a Neurology Assessment, an E.E.G., and an MRI) following a motor vehicle accident, claiming he suffered a head injury causing headaches and pain.

The respondent denied the benefits, arguing the applicant's headaches were cervicogenic and related to a soft-tissue injury.

The Tribunal found no objective medical evidence of a neurological disability or impairment resulting from the accident.

Relying on the reports of the insurer's examiner and other specialists, which aligned with the family doctor's findings, the Tribunal concluded the examinations were not reasonable and necessary.

The application was dismissed.

The applicant, a pedestrian injured in a 2010 motor vehicle accident, sought payment for a catastrophic impairment assessment totaling $26,919.25.

The respondent denied the claim.

The Licence Appeal Tribunal found that the applicant failed to provide sufficient objective medical evidence to suggest a reasonable possibility of catastrophic impairment.

The Tribunal held that the assessment was not reasonable and necessary, noting evidence of symptom amplification and a lack of support from treating physicians.

The application for the assessment costs, interest, and a special award was dismissed.