OLAT 2020

The applicant sought dispute resolution at the Licence Appeal Tribunal after the respondent insurer denied certain statutory accident benefits following a motor vehicle accident.

The core dispute involved the calculation of the applicant's pre-accident self-employment income for Income Replacement Benefits (IRBs).

The applicant relied on bank statements and an accountant's report, while the respondent calculated a lower amount due to the lack of supporting invoices or tax documents.

The Tribunal found the applicant failed to prove his self-employment income on a balance of probabilities, as bank statements alone were insufficient without corroborating evidence.

The Tribunal also dismissed claims for the balance of two psychological treatment plans, finding the proposed hourly rate for an unregulated psychotherapist unreasonable.

Claims for a special award and costs were also dismissed.

The appellant appealed the 45-day impoundment of her motor vehicle under section 50.2 of the Highway Traffic Act.

The vehicle was impounded after her son drove it while his licence was suspended.

The appellant argued that the impoundment caused exceptional hardship because she needed the vehicle to transport her autistic son, who refused to wear a mask on public transit, and because the isolation exacerbated her own PTSD.

The Tribunal found that there was no alternative to the impounded vehicle and that the impoundment posed a serious threat to the health and safety of both the appellant and her son.

The appeal was allowed and the vehicle was ordered released.

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

The respondent insurer denied the claims on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG) and were subject to the $3,500 funding limit.

The Licence Appeal Tribunal found that the applicant sustained predominantly minor soft tissue injuries and failed to provide compelling evidence of a psychological injury that would warrant removal from the MIG.

The Tribunal preferred the respondent's psychological assessments, which reviewed the full medical file, over the applicant's assessment, which lacked a review of the family physician's clinical notes.

The application for benefits and interest was dismissed.

The applicant sought statutory accident benefits for injuries sustained in a motor vehicle accident, including treatment plans for occupational therapy, physiotherapy, and psychological assessments.

The respondent insurer denied the benefits, relying in part on surveillance evidence.

The Tribunal gave little weight to the surveillance evidence, finding it unreliable and not contradictory to the applicant's self-reported limitations.

The Tribunal found the applicant was entitled to the costs of an attendant care assessment and occupational therapy, as well as physiotherapy, finding them reasonable and necessary.

The claim for a second psychological assessment was dismissed as it exceeded the statutory cap for a single assessment.

The Tribunal also awarded the applicant a 35% special award under O. Reg. 664, finding the respondent unreasonably withheld approval of the attendant care assessment after the applicant was removed from the Minor Injury Guideline.

The appellant appealed the 45-day impoundment of his motor vehicle, which was seized after his daughter drove it while her licence was suspended.

The appellant argued the impoundment caused exceptional hardship due to financial loss and inconvenience.

The Tribunal dismissed the appeal, finding that the appellant had an alternative to the impounded vehicle, as he and his family were able to use taxis to meet their immediate needs.

The Tribunal also declined to consider the appellant's late assertion that the vehicle had been stolen, as it was not raised in the Notice of Appeal.

The applicant, a self-employed taxi driver, sought income replacement benefits (IRBs) and a medical benefit for physiotherapy following a motor vehicle accident.

The insurer denied the benefits, relying on surveillance and multidisciplinary assessments that focused primarily on physical impairments.

The Tribunal found that the applicant suffered severe and ongoing psychological impairments, including major depressive disorder and post-traumatic stress disorder, which rendered him substantially unable to perform the essential tasks of his employment for the first 104 weeks, and completely unable to engage in any suitable employment thereafter.

The Tribunal awarded the claimed IRBs and interest.

Furthermore, the Tribunal ordered a 50% lump sum award under O. Reg. 664, finding that the insurer unreasonably withheld benefits by repeatedly ignoring the psychological diagnoses provided by its own assessors.

The claim for physiotherapy was dismissed for lack of evidence.

The applicant, a pedestrian struck by a vehicle in a parking lot, sought entitlement to attendant care benefits and various medical and rehabilitation benefits under the Statutory Accident Benefits Schedule.

The Licence Appeal Tribunal found the applicant entitled to a reduced attendant care benefit for a limited period, preferring the respondent's occupational therapy assessment which accounted for the applicant's right-hand dominance.

The Tribunal also approved treatment plans for chiropractic and physiotherapy services, finding them reasonable and necessary for pain relief.

However, claims for an orthopaedic mattress, extended psychological sessions, occupational therapy, and transportation expenses were dismissed due to non-attendance at an insurer's examination, lack of justification, and statutory limitations.

The applicant requested a reconsideration of a decision finding her statute-barred from disputing her claim for a non-earner benefit and a physiotherapy treatment plan.

The applicant argued the adjudicator erred in law by failing to apply the doctrine of discoverability established in Tomec v. Economical, and by failing to consider MRI evidence.

The Tribunal dismissed the request, finding that Tomec was distinguishable because the applicant's benefits were not pre-emptively denied prior to eligibility.

Furthermore, the MRI evidence did not support the applicant's position that she only later discovered her claim for a non-earner benefit, as it did not indicate a complete inability to carry on a normal life.

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

The respondent insurer suspended the IRBs after receiving medical assessment reports indicating the applicant had returned to work, and requested further documentation regarding post-accident income pursuant to section 33 of the Statutory Accident Benefits Schedule.

The applicant failed to produce the requested bank statements and maintained he had not returned to work.

The Tribunal found the respondent's request for documentation was justified, relying on surveillance evidence and assessors' reports that contradicted the applicant's claims.

Due to the applicant's non-compliance with section 33, the Tribunal dismissed the claim for IRBs and interest.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for a psychological assessment, physical therapy, and psychological treatment.

The respondent insurer denied portions of the treatment plans.

The Tribunal found that the applicant failed to prove the disputed costs for the psychological assessment and treatment were reasonable and necessary, as the insurer's examiners had found the proposed costs excessive or partially unnecessary.

However, the Tribunal awarded the cost of the physical therapy based on the recommendation of the applicant's family doctor, which the insurer failed to rebut with medical evidence.

The applicant sought a medical and rehabilitation benefit for a psychological assessment following a motor vehicle accident.

The respondent denied the benefit, asserting the applicant's injuries fell within the Minor Injury Guideline (MIG) and the $3,500 limit was exhausted.

The Tribunal found that the applicant's physical injuries were sprains and strains falling within the MIG.

The Tribunal rejected the applicant's claims of psychological impairment and chronic pain, finding insufficient medical evidence to support either diagnosis.

As the applicant's injuries were predominantly minor and the MIG limit was exhausted, the application was dismissed.

The applicant, an uninsured pedestrian injured in a hit-and-run, sought accident benefits from the Motor Vehicle Accident Claims Fund (MVACF).

MVACF denied a $1,950 in-home occupational therapy assessment and requested an insurer's examination (IE) by an occupational therapist, who deferred on causation.

MVACF then requested a second IE, which the applicant refused to attend.

The Tribunal found the proposed assessment was reasonable and necessary to address accident-related exacerbations of pre-existing injuries.

The Tribunal held the applicant was not barred from proceeding because MVACF's request for a second IE was not reasonably necessary, as the first IE improperly asked an occupational therapist to opine on medical causation.

The Tribunal also ordered a 40% special award against MVACF under O. Reg. 664, finding its conduct in adjusting the claim and maintaining the denial was unyielding and unreasonable given the applicant's vulnerability.

The applicant sought a non-earner benefit and a medical benefit for physiotherapy following a motor vehicle accident.

The Licence Appeal Tribunal found that the applicant failed to prove a complete inability to carry on a normal life, noting a lack of evidence comparing pre- and post-accident activities and significant pre-existing medical conditions.

The Tribunal also found the physiotherapy treatment plan was not reasonable and necessary due to a lack of compelling medical evidence.

The application was dismissed.

The applicant was involved in a motor vehicle accident and sought non-earner benefits.

The respondent raised a preliminary issue, arguing that the applicant was barred from proceeding with her claim under section 56 of the Statutory Accident Benefits Schedule because she failed to establish eligibility within the prescribed time limit.

The Tribunal found that the respondent had never issued a clear and unequivocal denial of a specific claim for the benefit, as no claim existed at the time of the purported denials.

Therefore, the limitation period under section 56 was not triggered, and the applicant was not barred from proceeding with her application.

The applicant sought payment for three assessments (two psychological and one physiatry) following a motor vehicle accident.

The Tribunal dismissed the claims for the psychological assessments, finding them to be a duplication of services and noting the applicant failed to provide evidence or submissions demonstrating they were reasonable and necessary.

The Tribunal dismissed the claim for the physiatry assessment for lack of jurisdiction, as the treatment plan had not been submitted or denied prior to the application being filed.

Claims for interest and an award were also dismissed.

The applicant insurer sought repayment of $9,197.65 in income replacement benefits (IRBs) paid to the respondent following a motor vehicle accident.

The insurer alleged the respondent wilfully misrepresented his employment status, as records later revealed he had been terminated from his job prior to the accident.

The respondent did not participate in the hearing.

The Tribunal found that the respondent had wilfully misrepresented his employment status and that the insurer met the procedural requirements for repayment under section 52 of the Schedule.

The Tribunal ordered the respondent to repay the IRBs with interest.

The applicant, who was a minor at the time of the motor vehicle accident, sought to dispute the denial of several treatment plans by the respondent insurer.

The application to the Licence Appeal Tribunal was filed more than two years after the denials.

The applicant argued that under section 6 of the Limitations Act, the limitation period was tolled until she turned 18.

The adjudicator held that the Limitations Act applies only to court proceedings and does not apply to the Tribunal.

The adjudicator also considered whether to extend the limitation period under section 7 of the Licence Appeal Tribunal Act but found that the applicant failed to satisfy the four-factor test.

The application was dismissed as statute-barred.

The applicant insurer accidentally deposited $1,114.60 into the respondent insured's bank account instead of paying an invoice for an examination under oath.

The insurer quickly realized the error, paid the correct party, and requested repayment from the insured.

The insured failed to respond to multiple requests or participate in the Tribunal proceedings.

The Tribunal found the insurer met the requirements of section 52 of the Statutory Accident Benefits Schedule and ordered the insured to repay the funds with interest.

The Tribunal declined to award costs against the insured.

The applicant sought a Non-Earner Benefit (NEB) following a motor vehicle accident.

The respondent insurer denied the claim, relying on independent medical examinations which concluded the applicant did not suffer a complete inability to carry on a normal life.

The Tribunal dismissed the application, finding the applicant's testimony unreliable due to numerous inconsistencies regarding her marital status, gym attendance, prior accidents, and work history.

The Tribunal accepted the respondent's unrefuted medical evidence and noted the applicant's failure to provide corroborating evidence for her claims.

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

The respondent initially denied several treatment plans but reversed its decision prior to the hearing.

The sole issue at the hearing was whether the applicant was entitled to an award under Ontario Regulation 664 for unreasonable delay or withholding of payments.

The Tribunal found that the respondent's reliance on medical assessments and subsequent reversal of its position did not constitute unreasonable behaviour.

The application for an award was dismissed.