OLAT 2020

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

The respondent denied funding for physiotherapy and a psychological assessment 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 Licence Appeal Tribunal found that the applicant's physical injuries were predominantly minor and that she failed to provide compelling evidence of a pre-existing condition or psychological impairment that would remove her from the MIG.

As the funding limit was exhausted, the claims for medical benefits, interest, and a special award were dismissed.

The applicant sought income replacement benefits (IRBs) and the cost of prescription medications following a motor vehicle accident.

The Licence Appeal Tribunal dismissed the claim for IRBs because the applicant failed to file a 2016 income tax return, meaning his pre-accident income was deemed to be nil under section 4(5) of the Statutory Accident Benefits Schedule.

The claim for prescription medications was also dismissed as the respondent had already paid the amount.

No interest was payable.

The applicant sought a determination that HST paid for attendant care services should be paid outside the attendant care benefit limit under the Statutory Accident Benefits Schedule, and claimed an award for unreasonable delay.

The Tribunal found that the Schedule's silence on HST, combined with FSCO Guidelines, should be interpreted in favour of the insured, meaning HST is a tax payable outside the benefit limit.

However, the Tribunal denied the claim for an award, finding the insurer's withholding of payment was based on its own interpretation of the Schedule and did not constitute unreasonable behaviour.

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

The Licence Appeal Tribunal found that the applicant sustained predominantly minor injuries, as there was insufficient evidence to establish that his chronic pain was more than a sequelae of his soft tissue injuries.

The Tribunal dismissed the claims for income replacement benefits due to lack of evidence, and denied the claimed medical and rehabilitation benefits for chiropractic treatment, an orthopaedic assessment, and a chronic pain assessment, finding them not reasonable and necessary.

The application was dismissed in its entirety.

The applicant sought a determination that she sustained a catastrophic impairment due to a mental or behavioural disorder following a motor vehicle accident.

The adjudicator applied the three-step approach from Pastore and found that while the accident caused a mental or behavioural disorder, the impact on the applicant's life was limited.

Preferring the respondent's medical experts who noted symptom exaggeration and validity concerns, the adjudicator concluded the applicant was only mildly impaired and did not meet the threshold for catastrophic impairment.

The application was dismissed.

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

The respondent denied two chiropractic treatment plans on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG) and the treatment was not reasonable and necessary.

The Tribunal found that the applicant's injuries were predominantly minor and that he had not established a pre-existing condition or chronic pain that would remove him from the MIG.

The Tribunal also found that the treatment plans were not reasonable and necessary.

Although the respondent failed to comply with the notice requirements under s. 38(8) of the Schedule for a brief period, no treatment costs were incurred during that time.

The application was dismissed.

The applicant sought a rehabilitation benefit of $11,865 for private hockey skills training following a motor vehicle accident.

The respondent denied the claim because the expense was incurred before a treatment plan was submitted, contrary to s. 38(2) of the Statutory Accident Benefits Schedule.

The Tribunal agreed, finding that the applicant's failure to submit a treatment plan prior to incurring the expense relieved the respondent of liability.

The Tribunal also held that it lacked jurisdiction to grant relief from forfeiture under s. 98 of the Courts of Justice Act, and that even if it had jurisdiction, relief would not be warranted.

The claim for an award for unreasonable delay was also dismissed.

The applicant sought statutory accident benefits following a 2013 motor vehicle accident.

The adjudicator found the applicant was entitled to medical benefits for social work counselling and physiotherapy, preferring the evidence of the applicant's assessors and the respondent's own psychological assessor over the respondent's paper-review orthopaedic assessment.

The adjudicator noted the applicant suffered from accident-related psychological impairments and chronic pain.

The claim for the cost of an OCF-3 was denied as it was not requested by the insurer and provided no new medical information.

The respondent's request for costs under Rule 19.1, alleging the applicant's reply was inflammatory, was dismissed as the conduct did not meet the high threshold of being unreasonable, frivolous, vexatious, or in bad faith.

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

The insurer denied the benefits, arguing the applicant did not suffer a complete inability to carry on a normal life and that the treatment was not reasonable and necessary.

The Tribunal dismissed the application, finding the applicant failed to meet the stringent test for a non-earner benefit, largely due to a lack of detailed comparison between her pre- and post-accident functioning and the impact of her pre-existing conditions.

The Tribunal also found the proposed treatment plan was not reasonable and necessary, preferring the insurer's medical evidence that the applicant had reached maximum medical improvement.

The applicant sought payment for various treatment and assessment plans following a motor vehicle accident.

The insurer denied the benefits, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) and the $3,500 coverage limit had been exhausted.

The Tribunal found that the applicant sustained predominantly minor injuries, specifically neck and back strains, and that her ongoing pain was attributable to pre-existing degenerative disc disease and osteoarthritis rather than the accident.

The Tribunal rejected the applicant's claims of chronic pain and psychological impairment, preferring the insurer's expert evidence.

As the applicant did not meet the criteria for a pre-existing condition exception, she remained subject to the MIG limit, and her claims for further benefits, interest, and a special award were dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident, including funding for chiropractic and psychological treatment plans, and argued for removal from the Minor Injury Guideline (MIG) due to chronic pain and psychological impairments.

The adjudicator found that the applicant's physical injuries were predominantly minor, consisting of sprains and strains, and that the evidence did not support a chronic pain diagnosis sufficient to warrant removal from the MIG.

Relying on the insurer's psychological assessment, the adjudicator also found no diagnosable psychological condition.

Consequently, the applicant failed to meet the burden of proving entitlement to treatment outside the MIG, and the disputed treatment plans were deemed not reasonable and necessary.

The application was dismissed.

The respondent insurer requested a reconsideration of a Tribunal decision which found that HST claimed with respect to attendant care services was to be paid outside of the attendant care benefit limits prescribed by the Statutory Accident Benefits Schedule.

The insurer argued the Tribunal made multiple errors of law, including finding that HST is not an 'expense' subject to the limits, relying on non-binding FSCO Bulletins, and misapprehending expert evidence.

The Tribunal dismissed the request for reconsideration, finding no significant errors of law that would warrant a different outcome.

The Tribunal affirmed that interpreting HST as a tax rather than a 'reasonable and necessary expense' is consistent with a plain reading of the Schedule.

The insurer requested a reconsideration of a decision awarding the insured funding for catastrophic impairment assessments.

The insurer argued the adjudicator erred in law by finding the assessments were not true rebuttal reports and were prepared for the purpose of a catastrophic application under s. 45 of the Schedule.

The adjudicator dismissed the reconsideration request, finding no errors of law that would materially affect the outcome.

The adjudicator maintained that the insured's right to be assessed for catastrophic impairment was not exhausted and that the timing of the application did not invalidate the funding request.

The insured's request for costs was also denied.

The applicant sought payment for a multidisciplinary catastrophic impairment (CAT) assessment totaling $25,779.25 following a 2013 motor vehicle accident.

The Tribunal held that entitlement to a CAT assessment is a qualified right governed by section 15 of the Schedule, requiring each constituent assessment to be reasonable and necessary, rather than a substantive right under section 25.

Reviewing the medical evidence, the Tribunal found the applicant displayed normal range of motion, functioned independently, and had minimal ongoing treatment, which was inconsistent with the severity of impairment required for a CAT designation.

The application was dismissed, along with claims for interest and a special award.

The applicant was injured in a 2015 motor vehicle accident and sought accident benefits, which the respondent insurer denied on the basis that her injuries fell within the Minor Injury Guideline (MIG).

The applicant had significant pre-existing injuries from prior accidents.

The Tribunal found that the subject accident exacerbated her pre-existing conditions and caused chronic pain, removing her from the MIG.

The Tribunal ordered the respondent to pay for a psychological assessment, finding it reasonable and necessary, along with interest.

However, the Tribunal dismissed the claims for an In-Home Attendant Care assessment and a non-earner benefit, as the applicant failed to prove a complete inability to carry on a normal life.

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

The Tribunal found that the insurer failed to provide a compliant denial notice for the non-earner benefit until November 26, 2016, and ordered payment of the benefit from the end of the 26-week deductible period until that date.

However, the Tribunal dismissed the claim for ongoing non-earner benefits, finding the applicant did not suffer a complete inability to carry on a normal life.

The claim for a medical benefit was also dismissed as the proposed treatment was not reasonable and necessary, given the applicant's extensive pre-existing back issues.

A claim for a special award under O. Reg 664 was dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident and applied for a catastrophic impairment determination.

The insurer requested insurer's examinations (IEs) coordinated through a third-party assessment company, CanAssess.

The applicant attended the physical examinations but subsequently revoked her consent for CanAssess's participation, preventing the release of the IE reports.

The Tribunal held that revoking consent to the third-party assessment company's participation is tantamount to failing to participate in the IE process under section 44 of the Schedule.

The Tribunal permitted the application to proceed but stayed the substantive hearing until the applicant complies with the IE process.

The applicant sought reconsideration of a Licence Appeal Tribunal decision that found her subject to the Minor Injury Guideline (MIG) and denied several disputed medical benefits.

The applicant argued the Tribunal erred in its application of s. 38 of the Statutory Accident Benefits Schedule, violated procedural fairness by admitting expert reports without cross-examination, and incorrectly assessed her physical and psychological impairments.

The adjudicator dismissed the request for reconsideration in full, finding no significant errors of law or fact, and concluding that the admission of the expert reports was an appropriate exercise of the Tribunal's procedural powers.

The adjudicator also affirmed that the applicant's injuries, including TMJ dysfunction and psychological distress, were properly classified as minor injuries or clinically associated sequelae.

The applicant sought statutory accident benefits following a single-vehicle motorcycle accident.

The insurer denied the benefits, arguing the applicant sustained no injuries and provided inconsistent accounts of the accident.

The Tribunal found the applicant's contemporaneous reports to first responders, which indicated a low-speed departure into a field without physical injury, to be the most reliable.

Consequently, claims for attendant care, physiotherapy, and an attendant care assessment were dismissed.

However, the Tribunal approved psychological treatment by a psychotherapist at a rate of $146.91 per hour, finding the insurer could not unilaterally impose a lower rate for an unregulated provider under the Guidelines.

The applicant applied for statutory accident benefits after slipping and falling on ice while shoveling her parking spot.

The respondent denied the claim on the basis that the incident did not meet the definition of an 'accident' under section 3(1) of the Statutory Accident Benefits Schedule.

The Licence Appeal Tribunal dismissed the application, finding that the applicant did not meet the purpose or causation tests.

The Tribunal held that shoveling an empty parking spot is not an ordinary and well-known activity to which automobiles are put, and the use or operation of the vehicle was not the direct cause or dominant feature of the applicant's injuries.