Licence Appeal Tribunal File Number: 23-013348/AABS
In the matter of an application pursuant to subsection 280(2) of the Insurance Act, RSO 1990, c I.8, in relation to statutory accident benefits.
Between:
Kevin Orme
Applicant
and
TD General Insurance Company
Respondent
DECISION
ADJUDICATOR:
Melanie Malach
APPEARANCES:
For the Applicant:
Gavin Cosgrove, Counsel
For the Respondent:
Nathan Tischler, Counsel
HEARD:
By way of written submissions
OVERVIEW
1Kevin Orme, the applicant, was involved in an automobile accident on May 29, 2018, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”). The applicant was denied benefits by the respondent, TD General Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The issues in dispute are:
i. Is the applicant entitled to $722,117.85 for Home Modifications, proposed by Accessible Daily Living in a treatment plan, dated September 7, 2023?
ii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
iii. Is the applicant entitled to interest on any overdue payment of benefits?
RESULT
3I find that the applicant is not entitled to the home modifications proposed in the treatment plan dated September 7, 2023, interest, or an award.
ANALYSIS
Background
4At the time of the accident on May 29, 2018, the applicant’s primary residence was at a farmhouse in Ontario (“Ontario home”). The applicant was renting his pre-accident home.
5On June 23, 2021, the applicant was designated catastrophically (“CAT”) impaired as a result of the accident. His injuries include the following:
i. A traumatic brain injury (“TBI”) with memory issues, cognitive challenges, light sensitivity and hypersensitive hearing;
ii. Chronic mechanical lower back pain;
iii. Limited use of his left arm, wrist and hand;
iv. Nerve damage in his legs causing severe hypersensitivity to temperature changes; and
v. Depression, anxiety and somatic symptoms disorder.
6On July 31, 2021, the applicant moved out of the Ontario home and moved to a new home on a farm in Prince Edward Island (“PEI home”).
7According to the applicant’s Affidavit dated May 16, 2024, a treatment plan requesting a home assessment of the applicant’s PEI home was submitted to the respondent on January 10, 2023. The treatment plan was denied by the respondent on January 18, 2023. On February 17, 2023, the applicant wrote to the respondent to re-consider the denial of the treatment plan, or alternatively, to permit an assessment of the applicant’s home where he resided at