OLAT 2020

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

The respondent denied certain medical and assessment benefits 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 Tribunal found that the applicant's physical injuries were soft tissue in nature and that he failed to provide sufficient medical evidence to establish a psychological impairment or chronic pain condition that would remove him from the MIG.

The application was dismissed.

The applicant was injured in a motor vehicle accident and sought payment for a chronic pain assessment and a neurological assessment under the Statutory Accident Benefits Schedule.

The insurer denied the treatment plans.

The Licence Appeal Tribunal found that the applicant failed to establish that either assessment was reasonable and necessary.

The applicant did not meet the AMA Guides criteria for chronic pain and lacked objective medical evidence supporting the need for a neurological assessment.

The application was dismissed.

The applicant sought various statutory accident benefits following a motor vehicle accident, including treatment plans for assistive devices, psychological services, hydrotherapy, chiropractic services, and catastrophic impairment assessments.

The insurer denied the benefits, arguing the applicant's ongoing issues were related to a significant pre-existing back condition and opioid dependence, not the accident.

The adjudicator dismissed the application, finding the applicant failed to provide sufficient medical evidence to prove the treatments were reasonable and necessary, and preferred the insurer's medical assessors who concluded the accident did not exacerbate the pre-existing condition.

The applicant was injured in a motor vehicle accident and sought medical benefits and cost of examinations under the Statutory Accident Benefits Schedule.

The insurer denied the claims, initially relying on the Minor Injury Guideline (MIG) limits, though it later conceded the applicant was removed from the MIG due to a psychological impairment.

The Tribunal found that the requested psychological services and driver reintegration assessment were reasonable and necessary, preferring the evidence of the applicant's psychologist over the contradictory reports of the insurer's expert.

However, the Tribunal dismissed the claims for physiotherapy, an orthopaedic assessment, and a functional abilities evaluation, finding insufficient objective evidence to support them and noting the applicant's own report that physical therapy was no longer helpful.

The claim for a special award under s. 10 of Regulation 664 was dismissed as the insurer's reliance on its experts' reports was not unreasonable.

The applicant, a pedestrian struck by a vehicle, sought statutory accident benefits including attendant care, a social work assessment, and catastrophic impairment assessments.

The respondent denied the attendant care benefits on the basis that the services were not incurred and the invoices lacked sufficient information.

The Tribunal found that the applicant had incurred the attendant care services and was entitled to the statutory maximum of $3,000 per month, despite some inaccuracies in the service providers' invoicing.

The Tribunal also awarded a portion of the social work assessment costs but denied the catastrophic impairment assessments as premature.

The applicant's claim for a special award under Regulation 664 was dismissed, as the respondent's conduct in investigating the discrepancies did not rise to the level of bad faith.

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

The insurer denied several physiotherapy treatment plans, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found that the applicant's pre-existing back pain was exacerbated by the accident, resulting in chronic pain that caused functional impairment, thereby warranting removal from the MIG.

The Tribunal approved one physiotherapy treatment plan for $1,197.00 as reasonable and necessary, but denied two subsequent plans due to a lack of evidence justifying their necessity.

The applicant's request for a special award under s. 10 was dismissed as the insurer's conduct was not unreasonable.

The applicant was injured in a motor vehicle accident and sought medical benefits from the respondent insurer for two treatment plans (OCF-18s) proposing chiropractic treatment, massage therapy, and physiotherapy.

The insurer denied the plans and argued at the hearing that they were invalid because they lacked physical signatures as required by s. 38(3) of the Schedule.

The Tribunal rejected the signature argument, noting the insurer failed to raise it prior to written submissions and the applicant subsequently provided signed copies.

On the merits, the Tribunal found the applicant was entitled to the massage therapy portion of the first treatment plan, as it was supported by contemporaneous medical records from her family physician and neurologist.

However, the Tribunal dismissed the claims for chiropractic treatment and the entirety of the second treatment plan, finding they were not supported by the medical evidence and that the applicant's condition had not improved despite ongoing chiropractic care.

Interest was awarded on the approved benefits.

The applicant requested a reconsideration of a Licence Appeal Tribunal decision that denied entitlement to medical benefits.

The applicant argued the Tribunal breached procedural fairness and made errors of law and fact by failing to properly consider evidence and arguments regarding the denial of treatment plans under section 38(8) of the Statutory Accident Benefits Schedule.

The adjudicator dismissed the request, finding that the Tribunal is not required to address every argument in its reasons, had provided sufficient reasons for finding the treatment plans were not reasonable and necessary, and that the respondent's section 44 reports met the requirements for denying the plans.

The respondent was involved in a motor vehicle accident and received Income Replacement Benefits (IRBs) from the applicant insurer.

The respondent subsequently returned to full-time work but failed to notify the insurer and continued to claim and receive IRBs.

The respondent abandoned his initial application to the Tribunal, and the insurer proceeded with a claim for repayment of the overpaid IRBs.

The Tribunal found that the respondent's failure to report his return to work and his submission of an election form for IRBs while working constituted wilful misrepresentation.

The insurer was ordered to be repaid $4,431.14 pursuant to section 52 of the Statutory Accident Benefits Schedule.

The applicant sought a determination that he sustained a catastrophic impairment as a result of a motor vehicle accident, along with claims for income replacement benefits, medical benefits for physiotherapy, housekeeping benefits, and cost of examinations.

The Tribunal found that the applicant's shoulder impairments were largely due to pre-existing conditions and natural degeneration, not the accident.

The Tribunal rejected the applicant's whole person impairment rating of 55%, finding that the assessors improperly included a 3% rating for medication use related to a pre-existing heart condition and an 18% rating for speculative future surgery.

The Tribunal also dismissed the claim for income replacement benefits, finding the applicant was not actively self-employed at the time of the accident due to a recent heart attack.

All claims were dismissed.

The applicant requested a reconsideration of a Tribunal decision that denied the cost of an orthopaedic assessment.

The applicant argued the Tribunal erred in law and fact by denying the assessment while relying on it to approve other treatment plans, and by failing to find the respondent's denial notice was deficient.

The Vice Chair dismissed the request, finding no misapprehension of evidence or errors of law or fact.

The Vice Chair noted that accepting part of an assessment does not obligate the Tribunal to find its cost reasonable and necessary, and that the applicant was attempting to reargue the case and raise new arguments not presented at the original hearing.

The applicant, a pedestrian struck by a vehicle, sought statutory accident benefits for chiropractic treatment.

The respondent denied the benefits 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 failed to submit an evidentiary record to prove his injuries were not predominantly minor or that the disputed treatment plans were reasonable and necessary.

The application was dismissed.

The applicant sought a medical benefit for physiotherapy in the amount of $1,899.96 following a motor vehicle accident.

The respondent denied the treatment plan, arguing the applicant's physical injuries were predominantly minor and the treatment was not reasonable and necessary.

The Tribunal found that the applicant failed to establish on a balance of probabilities that the treatment plan was reasonable and necessary, noting that the applicant reported only short-term relief from previous treatment.

The application was dismissed, and the respondent's claim for costs was also denied.

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

The respondent insurer paid benefits up to the $3,500 limit under the Minor Injury Guideline (MIG) and denied further claims.

The applicant applied to the Licence Appeal Tribunal, arguing her pre-existing conditions, chronic pain, and psychological issues warranted removal from the MIG.

The Tribunal found that the applicant sustained predominantly minor, soft tissue injuries and that her pain and psychological complaints were merely clinically associated sequelae.

The Tribunal dismissed the application, concluding the applicant was not entitled to benefits beyond the MIG limit.

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

The respondent denied treatment plans for chiropractic/massage therapy, a psychological assessment, and psychological treatment.

The Tribunal found the chiropractic and massage therapy plan was not reasonable and necessary, preferring the respondent's physiatry assessment which recommended a home exercise program.

However, the Tribunal found the psychological assessment and treatment plans were reasonable and necessary, concluding that the accident exacerbated the applicant's pre-existing anxiety and depression.

The Tribunal rejected the respondent's psychiatric assessment because it failed to address the applicant's in-vehicle anxiety and lacked objective testing.

The applicant's claim for a special award under Ontario Regulation 664 was dismissed as the respondent had relied on its own medical assessments.

The applicant sought accident benefits following a motor vehicle accident.

The respondent denied certain benefits, determining the applicant's injuries fell within the Minor Injury Guideline (MIG) and had exhausted the $3,500 limit.

The applicant argued she suffered from chronic pain syndrome, removing her from the MIG.

The Tribunal found the applicant's evidence, including a report from a chronic pain specialist, was inconsistent with her family physician's records and her own self-reporting.

The Tribunal preferred the respondent's physiatrist's evidence that the injuries were soft tissue sprains/strains within the MIG.

As the injuries were minor, the disputed treatment plans were not payable.

Claims for interest and a special award were also dismissed.

The applicant insurer sought repayment of $5,600.00 in income replacement benefits (IRBs) paid to the respondent insured, alleging the respondent wilfully misrepresented his return-to-work status.

The respondent had returned to full-time employment but continued to receive IRBs for over three months without notifying the insurer.

The respondent did not make submissions at the written hearing.

The Tribunal found that the respondent's failure to report his return to work constituted wilful misrepresentation.

The Tribunal ordered the respondent to repay the $5,600.00 overpayment plus interest.

The applicant sought various medical and assessment benefits under the Statutory Accident Benefits Schedule following a motor vehicle accident.

The respondent denied the treatment plans on the basis that they were not reasonable and necessary.

The Tribunal found that the applicant failed to meet his burden of proving that the proposed chronic pain program, orthopaedic assessment, psychological assessment, and physiotherapy treatments were reasonable and necessary, noting a lack of objective medical evidence and reliance on subjective complaints.

The application was dismissed, and claims for interest and a special award were denied.

The applicant sought medical and rehabilitation benefits following a motor vehicle accident.

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

The applicant argued her injuries were not minor, citing chronic pain and psychological impairments.

The Tribunal found the applicant's physical injuries were predominantly soft-tissue sprains and strains.

Relying on the respondent's section 44 assessments, the Tribunal concluded the applicant failed to prove her impairments warranted treatment beyond the MIG.

The disputed treatment plans were deemed not reasonable and necessary, and the application was dismissed.

The applicant sought income replacement benefits and funding for two chiropractic treatment plans following a motor vehicle accident.

The Licence Appeal Tribunal dismissed the application.

The Tribunal found the applicant was not entitled to income replacement benefits because he had returned to work and failed to provide sufficient evidence of his post-accident income to calculate any potential entitlement.

The Tribunal also denied the chiropractic treatment plans, finding they were not reasonable and necessary given the lack of improvement from prior similar treatment and the absence of support from the applicant's treating physicians.

Claims for an award and interest were consequently dismissed.