OLAT 2020

The applicant sought statutory accident benefits following a motor vehicle accident, including income replacement benefits (IRBs) and various medical and rehabilitation expenses.

The insurer denied the benefits, arguing the applicant suffered predominantly minor injuries subject to the $3,500 limit under the Minor Injury Guideline, which had been exhausted.

The Tribunal found the applicant did not suffer a substantial inability to perform the essential tasks of his employment and was therefore not entitled to IRBs.

Furthermore, the Tribunal concluded the applicant's injuries were predominantly minor, and since the $3,500 limit was exhausted, no further medical benefits were payable.

The application was dismissed.

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

The respondent denied the benefits and raised a preliminary issue that the applicant's claims were statute-barred under s. 56 of the Statutory Accident Benefits Schedule because the application was filed more than two years after the clear and unequivocal refusals.

The applicant argued that subsequent assessments and correspondence reset the limitation period.

The Tribunal found that the initial refusals were clear and that continuing assessments or repeating the refusal did not reset the limitation period.

The Tribunal also declined to extend the limitation period under s. 7 of the Licence Appeal Tribunal Act, finding no bona fide intention to appeal within the time limit, excessive delay, prejudice to the respondent, and lack of merit.

The application regarding the disputed benefits was dismissed as statute-barred.

The applicant, who was catastrophically impaired in a 2013 motor vehicle accident, sought payment for an in-home occupational therapy assessment to determine ongoing attendant care and housekeeping needs.

The respondent insurer denied the claim, arguing it was statute-barred under s. 56 of the Schedule because a previous denial was not disputed within two years, and that the assessment was not reasonable and necessary.

The Tribunal found that a 2016 partial settlement agreement did not permanently end the applicant's entitlement to these benefits and no settlement disclosure notice was provided.

The Tribunal concluded the claim was not statute-barred and that the assessment was reasonable and necessary given evidence of changes in the applicant's circumstances.

The applicant sought payment for an orthopaedic assessment and an attendant care assessment following a motor vehicle accident.

The respondent denied the orthopaedic assessment on the basis that it was available under OHIP, and denied the attendant care assessment as not reasonable and necessary and not incurred.

The Tribunal found that the assessments were not reasonable and necessary based on the medical evidence, which showed the applicant's injuries were mostly resolved or unrelated to the accident.

The claims for the assessments and interest were dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident, arguing his injuries fell outside the Minor Injury Guideline (MIG) due to chronic pain.

The applicant also argued the insurer was barred from relying on the MIG due to alleged non-compliance with the 10-day notice requirement under s. 38(8) of the Schedule.

The Tribunal found the insurer had complied with the notice requirements.

Furthermore, relying on medical assessments from both parties' experts which showed largely normal findings, the Tribunal concluded the applicant did not meet the AMA Guides criteria for chronic pain.

The application was dismissed as the injuries were predominantly minor and the $3,500 limit had been exhausted.

The applicant sought a medical benefit of $2,460.00 for a psychological assessment and interest under the Statutory Accident Benefits Schedule following a motor vehicle accident.

The matter proceeded by way of a written hearing.

The applicant failed to serve and file any written submissions or evidence by the deadline.

Consequently, the adjudicator found that the applicant failed to meet the onus of proving the treatment plan was reasonable and necessary.

The application was dismissed.

The respondent's request for costs was also denied, as the applicant's failure to file submissions did not amount to unreasonable, frivolous, vexatious, or bad faith conduct.

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

The respondent raised a preliminary issue that the claims were statute-barred under the two-year limitation period.

Prior to the written hearing, the applicant withdrew the preliminary issues in dispute.

The respondent subsequently sought costs, arguing the application was a duplication of previous proceedings at the Financial Services Commission of Ontario and was frivolous, vexatious, and in bad faith.

The Tribunal found that the previous proceedings did not result in a hearing on the merits or a binding settlement, and the applicant's withdrawal of the issues did not constitute unreasonable conduct.

The respondent's request for costs was dismissed.

The applicant sought various statutory accident benefits following a motor vehicle accident, including attendant care benefits and multiple treatment plans for psychological and physical injuries.

The Licence Appeal Tribunal denied the claim for attendant care benefits because the applicant failed to prove the expenses were incurred.

However, the Tribunal ordered the insurer to pay for several treatment plans, including a psychological assessment and physical therapy, because the insurer failed to provide proper medical reasons for its denials as required by section 38(8) of the Schedule.

The Tribunal also approved a chronic pain assessment and shockwave therapy based on medical evidence of ongoing pain, but denied other treatment plans for lack of evidence of reasonableness and necessity.

The claim for a special award was dismissed.

The applicant was injured in a motor vehicle accident and received attendant care benefits, which were subsequently denied.

The parties executed a partial release for past benefits up to May 11, 2017.

The applicant later submitted a new treatment plan and assessment form, which the respondent denied on the basis that the benefits had been terminated more than two years prior.

The respondent argued the applicant was statute-barred from disputing the denial.

The Tribunal found that while the initial denial was clear and unequivocal, the justice of the case required extending the limitation period under section 7 of the Licence Appeal Tribunal Act.

The Tribunal reasoned that the partial release only extinguished past claims, giving the applicant a bona fide belief that future claims remained open, and found minimal prejudice to the respondent.

The applicant sought payment for two physiotherapy treatment plans following a motor vehicle accident.

The insurer denied the plans based on section 44 assessments indicating the applicant had achieved maximal medical recovery.

The Tribunal found the applicant failed to demonstrate the treatment plans were reasonable and necessary, noting limited evidence of improvement, the applicant's self-reported normal function, and the lack of objective referrals for treatment.

The application was dismissed.

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

The respondent denied a treatment plan for physiotherapy on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG).

The applicant argued her injuries were outside the MIG due to chronic pain syndrome and pre-existing medical conditions.

The Licence Appeal Tribunal found that the applicant failed to prove her chronic pain caused functional impairment or disability beyond the sequelae of soft tissue injuries.

Furthermore, there was no compelling evidence that her pre-existing conditions would prevent maximal recovery under the MIG limit.

The application was dismissed.

The applicant requested a reconsideration of a Licence Appeal Tribunal decision which found her injuries were predominantly minor and subject to the Minor Injury Guideline (MIG) limits.

The applicant argued the adjudicator erred in law and fact by failing to remove her from the MIG due to pre-existing conditions and psychological impairments, and by applying an incorrect test for reasonable and necessary treatment.

The Tribunal dismissed the request, finding no error of law or fact.

The adjudicator correctly concluded that an exacerbation of a pre-existing injury is insufficient to remove an insured from the MIG without compelling evidence that it prevents maximal recovery, and properly precluded the psychological claims due to the applicant's failure to attend an insurer examination.

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

The insurer initially denied the treatment plan but approved it after receiving updated medical records.

The applicant proceeded to a hearing seeking an award for unreasonable delay and costs.

The Tribunal dismissed the application, finding that the insurer did not act unreasonably or in bad faith, as it approved the treatment plan within a reasonable time after receiving the necessary medical evidence.

The applicant was injured in a motor vehicle accident and sought various medical and rehabilitation benefits under the Statutory Accident Benefits Schedule for post-concussion syndrome and physical injuries.

The respondent insurer denied several treatment plans.

The Licence Appeal Tribunal found that the applicant was entitled to an in-home assessment, occupational therapy, a portion of a neuropsychological assessment, and assistive devices, as these were reasonable and necessary to address her cognitive and emotional symptoms.

However, claims for massage therapy, physiotherapy, and a rehabilitation support worker were dismissed because the applicant had reached maximum medical improvement from an orthopedic perspective and passive treatments provided only temporary relief.

The applicant was injured in a motor vehicle accident and sought payment for a medical cannabis treatment plan to address chronic neck and back pain and sleep issues.

The respondent insurer denied the treatment plan, relying on a section 44 assessment that concluded cannabis was not reasonable and necessary for chronic pain.

The Tribunal preferred the evidence of the applicant's chronic pain specialist and cannabis clinic physician, finding that the treatment goals of reducing pain were reasonable and likely to be achieved.

The Tribunal ordered the respondent to pay the cost of the treatment plan, plus interest on the overdue amount.

The applicant sought statutory accident benefits for an impairment assessment, a physiatry assessment, and a treatment plan for physiotherapy and massage therapy following a motor vehicle accident.

The adjudicator found that the impairment assessment and the physiotherapy treatment plan were not reasonable and necessary, noting the applicant's return to full-time work and independence in self-care.

While the physiatry assessment was also found not to be reasonable and necessary, the adjudicator held that the respondent failed to provide a compliant denial under section 38(8) of the Schedule.

Consequently, the applicant was entitled to the incurred costs of the physiatry assessment along with interest.

The applicant, who was involved in a motor vehicle accident, sought payment for various treatment plans including a neurological assessment, physiotherapy, chiropractic treatment, and psychological services under the Statutory Accident Benefits Schedule.

The respondent insurer denied the benefits.

The Licence Appeal Tribunal found that the applicant failed to prove on a balance of probabilities that the disputed treatment plans were reasonable and necessary.

The adjudicator noted inconsistencies in the applicant's self-reporting to assessors compared to her family doctor's records, and found the expert reports provided by both parties to be problematic or unpersuasive.

The application was dismissed in its entirety.

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

The respondent failed to respond to a physiotherapy treatment plan within the required 10 days and did not approve or pay for it until almost a year later.

The Tribunal found that the benefit was overdue and ordered the respondent to pay interest.

Furthermore, the Tribunal found that the respondent unreasonably withheld and delayed payment without explanation, and ordered a special award of 25% under Regulation 664.

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

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

The adjudicator found that the applicant's injuries, which included radiculopathy and possible myeloradiculopathy as noted by the respondent's own neurological assessor, exhibited neurological signs that removed him from the MIG.

The adjudicator approved two physiotherapy treatment plans, finding one reasonable and necessary for pain relief, and the other payable because the respondent failed to provide adequate medical reasons for its denial under s. 38(8) of the Schedule.

An attendant care needs assessment was also approved.

However, the applicant's claim for a special award under Regulation 664 was dismissed as there was insufficient evidence that the respondent acted unreasonably.

The applicant was injured in an automobile accident in Alberta while driving a vehicle registered and insured in Alberta.

After receiving benefits under the Alberta policy, the applicant applied to the Licence Appeal Tribunal for statutory accident benefits under the Ontario Schedule.

The respondent insurer challenged the Tribunal's jurisdiction.

The Tribunal held that under section 226(2) of the Insurance Act, the applicant's policy was excluded from the scope of the Act because the vehicle was not required to be registered in Ontario and the policy was not in an approved Ontario form.

The Tribunal further found that the Power of Attorney and Undertaking (PAU) signed by the insurer did not grant jurisdiction over an out-of-province accident involving an out-of-province policy.

The application was dismissed for lack of jurisdiction.