OLAT 2020

The applicant sought payment for a treatment plan in the amount of $2,672.45 for an EMG and nerve conduction studies following a motor vehicle accident.

The respondent denied the treatment plan outside the 10-day period required by section 38(8) of the Statutory Accident Benefits Schedule and provided insufficient medical reasons.

However, the applicant incurred the cost of the examination on the 11th day after submitting the plan, which was prior to the 11th business day.

The Tribunal held that section 38(11)2 limits entitlement to goods and services incurred starting on the 11th business day.

Because the expense was incurred prematurely, the applicant was not entitled to the cost of the examination, and the application was dismissed.

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

At the time of the accident, the applicant was on an unpaid leave of absence due to a prior slip and fall and was not receiving any employment income.

The Tribunal found that the applicant did not meet the definition of "employed" under section 5 of the Statutory Accident Benefits Schedule because she was not receiving remuneration, and therefore was not entitled to IRBs.

The respondent insurer sought repayment of $17,563.50 in IRBs that were paid in error.

The Tribunal dismissed the repayment claim, finding that the insurer failed to provide proper notice under section 64(2)(e) of the Schedule because the notice was sent electronically without the applicant's consent.

The application was dismissed.

The applicant requested a reconsideration of a previous Tribunal decision which found that his accident-related injuries were predominantly minor.

The applicant argued that the Tribunal failed to consider medical evidence and was biased in relying on surveillance evidence, amounting to a violation of procedural fairness and a significant error of law or fact.

The Tribunal denied the request, finding that it had considered the medical evidence but found the surveillance evidence more persuasive, and that there was no error of law or fact that would have resulted in a different decision.

The applicant requested a reconsideration of a Tribunal decision that found her statute-barred from applying for dispute resolution due to her failure to attend an insurer's psychological examination.

The applicant argued the Tribunal erred in law and failed to exercise its discretion to allow the application despite the non-attendance.

The Tribunal dismissed the reconsideration request, finding no error of law or fact, as the applicant provided no reasonable explanation for missing the examination and no evidence that she attempted to reschedule it.

The applicant was injured in a motor vehicle accident and sought various medical and rehabilitation benefits.

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

The applicant argued that she suffered from chronic pain and had pre-existing conditions that warranted removal from the MIG.

The Tribunal found that the applicant failed to provide compelling medical evidence or a diagnosis of chronic pain from a qualified expert.

Furthermore, the applicant did not provide compelling evidence that her pre-existing conditions would prevent maximal recovery within the MIG limits.

The Tribunal concluded the applicant's injuries were predominantly minor and subject to the MIG.

As the MIG limits were exhausted, the claims for additional benefits and interest were dismissed.

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

The respondent initially denied the plans, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) and the plans were not reasonable and necessary.

At the hearing, the respondent conceded the MIG did not apply but maintained the plans were not reasonable and necessary.

The Tribunal found the treatment plans were reasonable and necessary, as the goals were reasonable, were being met to a reasonable degree, and the costs were reasonable.

The Tribunal ordered the respondent to pay for the treatment plans with interest, but denied the applicant's request for a special award, finding the respondent's initial denial was not unreasonable given its insurer examination report.

The applicant sought attendant care benefits, interest, and an award under s. 10 of O. Reg. 664 following a motor vehicle accident.

The Tribunal found that the applicant failed to prove the attendant care services were reasonable and necessary, noting a lack of detail in the invoices and a nearly year-long gap before services were allegedly incurred.

As no benefits were payable, the claims for interest and a bad faith award were also dismissed.

The applicant was injured in a motor vehicle accident and sought dispute resolution at the Licence Appeal Tribunal after the respondent insurer denied a treatment plan for a chronic pain assessment.

The adjudicator found that the assessment was reasonable and necessary, given compelling evidence from the applicant's treating physicians of constant and severe pain.

However, the adjudicator dismissed the applicant's claim for a special award under Ontario Regulation 664, finding no evidence that the insurer unreasonably withheld or delayed payments.

The applicant was awarded the cost of the assessment and applicable interest.

Aviva requested a reconsideration of a Licence Appeal Tribunal decision that awarded D.S. two chiropractic treatment plans and interest.

Aviva argued the Tribunal erred by not addressing whether the benefits were 'incurred' under section 3(7) of the Statutory Accident Benefits Schedule.

The adjudicator dismissed the reconsideration request, finding that a tribunal may order a treatment plan reasonable and necessary, with payment and interest payable only once the expense is actually incurred.

The adjudicator also granted D.S.'s request to amend the original Order to include a third treatment plan that was approved in the reasons but inadvertently omitted from the final Order.

The applicant sought statutory accident benefits following a motor vehicle accident, disputing the insurer's determination that her injuries fell within the Minor Injury Guidelines (MIG).

She claimed entitlement to ongoing income replacement benefits (IRBs) and a $23,581.00 medical benefit for assessments.

The Licence Appeal Tribunal found that the applicant's injuries were confined to the MIG, noting that her family doctor's records, surveillance evidence, and insurer's examinations contradicted her claims of chronic pain and functional limitation.

The Tribunal dismissed the claim for IRBs, finding the applicant did not suffer a substantial inability to perform the essential tasks of her employment, and denied the medical benefit as the proposed assessments were not reasonable and necessary.

The application was dismissed in its entirety.

The applicants were involved in a motor vehicle accident and sought attendant care benefits (ACBs) from their insurers.

Following a reconsideration decision that found an error of law in calculating the quantum of ACBs, the matter was sent back for a written hearing.

The Tribunal determined the quantum of ACBs using the 'minimum award approach' because the applicants failed to provide a breakdown of the actual hours spent on each level of care.

The Tribunal awarded S.K. $5,073.50 and R.K. $5,606.98 in ACBs, plus interest on overdue payments.

Additionally, the Tribunal found that the insurers unreasonably withheld payment of the minimum benefits owing after the reconsideration decision and ordered a lump sum award of $1,500 for each applicant under s. 10 of O. Reg. 664.

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

The insurer denied the claims, arguing the injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found that while the applicant's physical injuries were predominantly minor, her psychological diagnosis of Adjustment Disorder with Mixed Anxiety and Depressed Mood justified removal from the MIG.

The Tribunal approved a psychological assessment as reasonable and necessary, but denied the proposed chiropractic treatment plans, finding the applicant had reached maximum medical recovery for her physical impairments.

The applicant was injured in a motor vehicle accident and sought medical benefits for chiropractic treatment outside the Minor Injury Guideline (MIG).

The applicant argued she suffered from chronic pain syndrome and a psychological impairment, relying on a chiropractor's report.

The Tribunal found the chiropractor's psychological diagnosis was outside his scope of expertise and unsupported by objective medical evidence.

Preferring the respondent's physiatry assessment, the Tribunal concluded the applicant's injuries were predominantly minor and subject to the $3,500 MIG limit.

The claims for additional chiropractic treatment and interest were dismissed.

The applicant requested a reconsideration of a Tribunal decision denying entitlement to income replacement benefits and medical benefits.

The applicant argued the Tribunal made errors of law or fact regarding the disclosure of productions, the date of the applicant's baby's birth, and the timelines of visits to her family doctor.

The adjudicator found that the alleged errors were either not part of the decision's analysis or were not significant enough to affect the outcome.

The request for reconsideration was dismissed.

The applicant was injured in a motor vehicle accident and sought various medical and rehabilitation benefits from the respondent insurer under the Statutory Accident Benefits Schedule.

The insurer denied several treatment plans on the basis that they were not reasonable and necessary, relying on section 44 assessments.

The Tribunal found that the applicant was entitled to $338.61 for a therapeutic pool membership and $2,359.99 for chiropractic treatment, as these were reasonable, necessary, and incurred.

However, the Tribunal dismissed the claims for the remaining treatment plans, finding that the applicant failed to meet her burden of proving they were reasonable and necessary, particularly given the lack of substantive analysis and the inclusion of excessive ancillary fees.

Interest was awarded on the overdue benefits.

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

The Licence Appeal Tribunal dismissed the application, finding that the applicant did not suffer a complete inability to engage in employment.

The Tribunal relied on surveillance evidence showing the applicant socializing, driving, and taking vacations, which contradicted his claims of severe impairment.

The Tribunal also found the claimed medical benefits were not reasonable and necessary, as previous treatments had not improved his condition and independent medical examinations found him capable of working.

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

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

The applicant argued that chronic pain, psychological symptoms, and pre-existing chest pain excluded him from the MIG.

The Tribunal found that the applicant's physical injuries were predominantly minor (sprains and strains) and that the evidence of psychological impairment and chronic pain was unreliable.

Furthermore, there was no compelling evidence that the applicant's pre-existing chest pain prevented maximal recovery within the MIG limits.

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

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

The insurer denied certain medical benefits, arguing the injuries fell within the Minor Injury Guideline (MIG) and its $3,500 funding limit.

The Tribunal found the applicant suffered from chronic pain syndrome, removing him from the MIG.

The Tribunal ordered the insurer to pay for the disputed treatment plans, plus interest, and awarded the applicant 40% of the withheld amounts under section 10 of O. Reg. 664 due to the insurer's unreasonable denial without obtaining its own medical assessment.

The applicant sought statutory accident benefits for physiotherapy and a psychological assessment following a May 2016 motor vehicle accident.

The Licence Appeal Tribunal dismissed the application, finding the applicant failed to prove the treatments were reasonable and necessary as a result of the subject accident.

The Tribunal noted significant gaps in the medical records and unrefuted evidence of subsequent intervening accidents, including another motor vehicle accident and a cycling accident, which likely caused the current injuries.

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

The respondent insurer limited the applicant to the $3,500 Minor Injury Guideline (MIG) funding limit.

The Tribunal found that the applicant suffered accident-related psychological injuries, including depression and anxiety, which removed him from the MIG.

The Tribunal ordered the respondent to pay for a psychological assessment and a psychological treatment plan, plus interest on the incurred assessment, but denied the remaining disputed treatment plans as the applicant failed to prove they were reasonable and necessary.