OLAT 2020

The applicant sought statutory accident benefits following a rear-end collision, claiming his injuries fell outside the Minor Injury Guideline (MIG) due to chronic pain syndrome and psychological impairments.

The Licence Appeal Tribunal found that the applicant's injuries were predominantly minor, relying on insurer examinations that concluded his physical and psychological symptoms did not warrant removal from the MIG.

The Tribunal gave little weight to the applicant's pain specialist report, finding it relied entirely on self-reporting and contradicted objective evidence.

The applicant's claims for a $13,667.32 chronic pain program, an award for unreasonable delay, interest, and costs were all dismissed.

The applicant sought payment for a psychological treatment plan following a motor vehicle accident.

The insurer denied the plan, arguing it was not reasonable and necessary.

The Tribunal found that the applicant failed to demonstrate the treatment was reasonable and necessary, noting that the most recent psychological assessment revealed no diagnosable condition and that the applicant's current complaints appeared related to a subsequent accident.

The application was dismissed.

The respondent insurer requested a reconsideration of a decision finding that the applicant was not precluded from applying to the Tribunal for failing to attend scheduled insurer's examinations.

The insurer argued the Tribunal applied an inappropriately stringent standard to the reasons provided in the examination notices and failed to consider the applicant's lack of medical evidence.

The Tribunal dismissed the request, finding no error of law or fact, and affirmed that an insurer must provide sufficient medical reasons in its notice before relying on section 55(2) of the Schedule to bar an application.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits from the respondent insurer.

The applicant claimed entitlement to a physical treatment balance, an orthopaedic assessment, and a chronic pain assessment, as well as a special award and interest.

The Tribunal dismissed all claims, finding that the applicant failed to prove the proposed treatment and assessments were reasonable and necessary.

Specifically, the Tribunal noted that the applicant had already received two OHIP-funded orthopaedic assessments, which constituted reasonably available medical benefits under another plan or law.

Furthermore, the evidence did not support the necessity of a chronic pain assessment, as the applicant's pain was managed with medication and he had not sought specialized chronic pain treatment.

The applicant was injured in a motor vehicle accident and sought a medical benefit of $2,961.72 for a kinesiologist-supervised exercise program.

The respondent denied the claim, arguing the applicant had reached maximum medical recovery and could perform exercises independently.

The Tribunal found the treatment plan was reasonable and necessary, preferring the evidence of the applicant's treating practitioners that supervision was required to avoid aggravating her impairments and to support her psychological well-being.

The applicant was awarded the claimed benefit.

The applicant sought payment for two chiropractic treatment plans totalling over $16,000 following a motor vehicle accident.

The applicant also brought a motion to add several new issues to the dispute after written submissions had closed.

The Tribunal dismissed the motion to add new issues, finding it would be procedurally unfair to the respondent.

On the substantive claims, the Tribunal found that the applicant had incurred all of the chiropractic expenses prior to submitting the required treatment plans (OCF-18s).

As none of the exceptions under s. 38(2) of the Schedule applied, the insurer was not liable to pay for the expenses.

The application was dismissed.

The respondent insurer sought reconsideration of a Tribunal decision awarding the applicant non-earner benefits, a treatment plan for concussion management, interest, and a special award under s. 10 of O. Reg. 664.

The Vice Chair granted the reconsideration in part.

The Tribunal's award of the concussion management treatment plan was set aside because the applicant had failed to submit an OCF-18 as required by s. 38(2) of the Schedule.

The s. 10 award was also set aside, as the Tribunal had misapplied the legal test for unreasonable delay and relied on a significant factual error regarding the amount of medical benefits previously paid by the insurer.

The Tribunal's decision on non-earner benefits was upheld, but the interest calculation was varied.

The applicant sought a Non-Earner Benefit (NEB) following a motor vehicle accident but failed to submit a completed Disability Certificate (OCF-3) until 121 weeks after the accident.

The insurer denied the claim on the basis that the OCF-3 was submitted beyond the 104-week eligibility period.

The Tribunal held that the applicant was statute-barred from proceeding with the NEB claim under section 36 of the Schedule, as the benefit is not payable for any period prior to the submission of the OCF-3, and the 104-week eligibility period under section 12 had already expired.

The applicant's argument of having a reasonable explanation for the delay was rejected as irrelevant to the mandatory procedural requirements.

The applicant and respondent both filed requests for reconsideration of a Licence Appeal Tribunal decision regarding statutory accident benefits.

The applicant argued the adjudicator made errors of fact and law in finding no causal link between the motor vehicle accident and the applicant's subsequent heart failure and stroke.

The Tribunal dismissed the applicant's request, finding the adjudicator correctly applied the 'but for' test and made no reviewable errors in weighing the medical evidence.

The respondent argued the adjudicator violated procedural fairness by awarding the cost of an attendant care assessment based on section 25(1)4 of the Schedule, a provision neither party had addressed in submissions.

The Tribunal granted the respondent's request, finding the adjudicator should have sought submissions on the section, and ordered the issue of the attendant care assessment to be re-heard.

The applicant sought statutory accident benefits following a motor vehicle accident, including attendant care benefits, medical and rehabilitation benefits, and interest.

The Licence Appeal Tribunal dismissed the claim for attendant care benefits, finding the applicant failed to prove the expenses were incurred.

The Tribunal granted the cost of a mattress as an assistive device, finding it reasonable and necessary to address the applicant's sleep disturbance.

The Tribunal also awarded $924.24 for occupational therapy services because the insurer's denial letter failed to provide sufficient medical and other reasons as required by s. 38(8) of the Schedule.

The remaining claims for occupational therapy and chiropractic services were dismissed as not reasonable and necessary.

The Tribunal drew an adverse inference against the applicant for failing to comply with a production order regarding her pre-accident medical records.

The applicant sought a reconsideration of a Licence Appeal Tribunal decision that denied his claim for income replacement benefits.

The applicant argued that the adjudicator exhibited a reasonable apprehension of bias, made errors of law and fact, and that new evidence warranted a different result.

The Vice Chair dismissed the reconsideration request, finding that the adjudicator reasonably weighed the evidence, no errors of law or fact were made, and the proposed new evidence could have been obtained prior to the hearing and would not have altered the outcome due to significant credibility issues.

The applicant was catastrophically impaired in a motor vehicle accident and received a non-earner benefit (NEB) from the respondent insurer.

The insurer denied further payment of the NEB in October 2016.

The applicant appealed the denial to the Licence Appeal Tribunal in November 2018, beyond the two-year limitation period under section 56 of the Statutory Accident Benefits Schedule.

The insurer brought a motion to dismiss the appeal as time-barred.

The Tribunal found that the insurer had properly sent the denial notice by mail and fax.

Applying the four-part test under section 7 of the Licence Appeal Tribunal Act, the Tribunal declined to extend the limitation period, finding no bona fide intention to appeal within the period and no valid reason for the delay.

The application for the NEB was dismissed as time-barred.

The applicant sought reconsideration of a Tribunal decision that denied entitlement to interest, an award, and costs related to an approved treatment plan.

The applicant argued the Tribunal erred in law by failing to consider the remedial nature of the legislation, the applicant's chronic pain, and the provisions for interest under the Schedule.

The adjudicator found no error of law or fact, noting that the insurer approved the treatment plan once sufficient medical evidence was provided, and there was no basis for costs or an award.

The request for reconsideration was denied.

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

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

The applicant argued she was removed from the MIG due to a partial rotator cuff tear, right arm radiculopathy, and a psychological impairment.

The Tribunal found that the applicant failed to prove on a balance of probabilities that she suffered from radiculopathy or an accident-related psychological impairment that would remove her from the MIG.

As the injuries were predominantly minor and the funding limit was exhausted, the claims for treatment plans and interest were dismissed.

The applicant sought $1,966.30 for a physiotherapy treatment plan following a motor vehicle accident.

The adjudicator dismissed the application, finding that the applicant failed to prove the treatment was reasonable and necessary.

The applicant did not submit any contemporaneous medical evidence to support the treatment plan, whereas the respondent provided insurer's examination reports from a physiatrist and an orthopaedic surgeon indicating no physical impairment requiring facility-based treatment.

The applicant sought medical benefits for chiropractic treatment and PRP injections following a motor vehicle accident.

The Tribunal found that while the accident exacerbated the applicant's pre-existing right shoulder rotator cuff tear, the proposed treatment plans were not reasonable and necessary.

The evidence indicated that past chiropractic treatment had not been effective in reducing pain, and there was insufficient evidence to support the efficacy of PRP injections for the impairment.

Both claims for medical benefits were dismissed.

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

The respondent insurer determined the injuries were predominantly minor and subject to the $3,500 limit under the Minor Injury Guideline (MIG).

The applicant argued for removal from the MIG based on a pre-existing right shoulder injury and a chronic pain disorder with psychological impacts.

The Tribunal found the applicant failed to provide compelling medical evidence that her pre-existing condition prevented her from achieving maximal recovery, or that she suffered from chronic pain or psychological issues beyond the sequelae of her minor soft tissue injuries.

The Tribunal also found the insurer provided adequate reasons for denying the treatment plans.

The application was dismissed.

The applicant sought a stay or an adjournment sine die of his Tribunal application for housekeeping and home maintenance benefits until he obtained a catastrophic impairment designation.

The respondent argued that, following the Court of Appeal's decision in Tomec, the limitation period does not begin to run until the applicant is deemed catastrophically impaired, so the application should be dismissed without prejudice.

The Adjudicator agreed with the respondent, finding that keeping the file open indefinitely would contravene the Tribunal's mandate for efficient and timely resolution.

The application was dismissed without prejudice.

The applicant sought to remove a condition from its liquor licence that required it to notify specific objectors prior to any application to transfer the licence.

The condition was imposed in 2002.

The applicant demonstrated that the original objectors no longer resided at their previous addresses, and the respondent agreed that there had been a change in circumstances and that it no longer sought to impose such conditions.

The Tribunal found a change in circumstances and ordered the condition removed.

The applicant was involved in a motor vehicle accident and sought statutory accident benefits, including non-earner benefits (NEBs) and medical benefits for physiotherapy and a chronic pain assessment.

The respondent insurer denied the benefits.

The Licence Appeal Tribunal found that the applicant suffered a complete inability to carry on a normal life due to severe psychological impairment resulting from the accident, which continuously prevented her from engaging in her pre-accident activities of caring for her children and pursuing her vocational goals.

The Tribunal awarded NEBs of $185.00 per week and interest.

However, the Tribunal dismissed the claims for physiotherapy and a chronic pain assessment, finding insufficient evidence that they were reasonable and necessary, as the applicant's impairment was fundamentally psychological rather than physical.