Ontario Licence Appeal Tribunal

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

The respondent denied the benefits, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found that the applicant failed to provide persuasive medical evidence to support removal from the MIG.

Consequently, the disputed treatment plans were denied.

The Tribunal also dismissed the claim for income replacement benefits, finding the applicant failed to provide evidence of accident-related functional impairments preventing him from working.

Claims for interest and an award were also dismissed.

The applicant requested reconsideration of a Tribunal decision that found it lacked jurisdiction to determine entitlement to a non-earner benefit because the applicant had not submitted a completed disability certificate (OCF-3).

The applicant argued that the respondent's delay in providing the application forms constituted a reasonable explanation for the delay, and that requiring the form years later was futile.

The Tribunal dismissed the reconsideration request, finding that while the delay explained the late filing, it did not excuse the ongoing failure to submit the mandatory OCF-3 once the forms were received.

As there was no completed application or denial, the Tribunal correctly concluded it had no jurisdiction under s. 280 of the Insurance Act.

The applicant requested reconsideration of a Licence Appeal Tribunal decision that denied his claims for an award and interest.

In the initial hearing, the applicant had withdrawn his substantive claim for an attendant care benefit.

The Vice-Chair dismissed the reconsideration request, finding no error of law or fact, as the Tribunal lacked jurisdiction to grant an award or interest when no substantive benefits were found to be payable.

The applicant's attempt to introduce new evidence in the form of attendant care invoices was also rejected, as it would not have affected the outcome given the withdrawal of the underlying benefit claim.

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

The respondent denied the claim for catastrophic impairment and scheduled insurer's examinations (IEs).

The respondent alleged the applicant failed to attend rescheduled IEs and sought to dismiss the application as a preliminary issue.

The Tribunal found the respondent's allegation was pre-emptive and speculative, as there was no evidence the applicant failed to attend the most recently scheduled IEs.

The Tribunal held the respondent did not meet its burden to show non-attendance, and ordered the parties to proceed to the substantive hearing.

The applicant sought accident benefits following a motor vehicle accident, claiming removal from the Minor Injury Guideline (MIG) due to physical injuries, a psychological impairment, and chronic pain.

The adjudicator found insufficient evidence to support removal from the MIG, preferring the respondent's psychological assessment over the applicant's because it was based on clinical testing and medical records rather than solely self-reported data.

The applicant also failed to establish a functional impairment from chronic pain.

The application for a psychological assessment, interest, and a section 10 award was dismissed.

The applicant sought accident benefits following a motor vehicle accident, claiming removal from the Minor Injury Guideline (MIG) due to chronic pain and psychological impairments.

The Tribunal found that the applicant's injuries were predominantly minor.

Relying on the respondent's section 44 physiatry and psychological assessments, the Tribunal concluded there was no objective evidence of chronic pain with functional impairment or a psychological condition.

As the applicant remained within the MIG, the disputed treatment plans were not payable, and claims for an award and interest were dismissed.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for a psychological assessment, assistive devices, and occupational therapy services.

The Tribunal found the psychological assessment and assistive devices were not reasonable and necessary, relying on independent examinations and a lack of contemporaneous evidence supporting the claims.

However, the Tribunal approved the occupational therapy services, finding them supported by functional capacity assessments and a physiatrist's diagnosis of chronic pain syndrome.

The claim for an award under s. 10 of Regulation 664 was dismissed, but interest was awarded on the overdue occupational therapy benefits.

The insured requested a reconsideration of a Licence Appeal Tribunal decision that ordered her to repay Income Replacement Benefits (IRBs) and denied her claims for physiotherapy treatment plans.

The adjudicator granted the reconsideration in part, finding that the original hearing adjudicator committed a material breach of procedural fairness by excluding the insured's reply submissions.

Furthermore, the original decision contained errors of law by incorrectly concluding that non-compliance with section 33 of the Schedule allowed the insurer to claim repayment for past paid IRBs, and by failing to consider the insurer's compliance with section 38 and the insured's expert medical evidence regarding the treatment plans.

The substantive issues were remitted for a new hearing.

The applicant sought $1,602.05 for medication expenses, an award for unreasonable delay, and interest following a motor vehicle accident.

The applicant claimed the accident caused a re-emergence of epileptic seizures and psychological symptoms.

The Tribunal dismissed the application, finding the applicant failed to prove the medications were reasonable and necessary to treat accident-related injuries.

The Tribunal preferred the evidence of the insurer's neurologist, who found no traumatic neurological injury explaining the seizures, and noted the applicant's treating neurologist also found no connection to the accident.

As no benefits were payable, the claims for interest and an award were also dismissed.

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

The Tribunal found the applicant entitled to outstanding amounts for psychological and psychotherapy services, accepting that a registered psychotherapist could reasonably bill at a rate comparable to a psychologist when providing structured cognitive behavioural therapy under clinical supervision.

The Tribunal also approved a chiropractic treatment plan and assessments for neurology and chronic pain, finding them reasonable and necessary based on ongoing symptoms.

However, a comprehensive chronic pain program was denied due to insufficient evidence of severity and functional decline.

The applicant's claim for a special award was dismissed.

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

The respondent insurer initially confined the applicant to the Minor Injury Guideline (MIG) and denied various treatment plans and income replacement benefits (IRB).

The Tribunal found the applicant's injuries were non-minor, removing her from the MIG.

The Tribunal awarded IRB for a specific period due to the insurer's non-compliance with s. 36(4) response timelines, but denied post-104 IRB.

The Tribunal approved treatment plans for physiotherapy, a psychological assessment, and a chronic pain assessment, finding them reasonable and necessary.

Notably, the Tribunal ordered a 35% special award against the insurer under s. 10 of Reg. 664, finding its conduct in adjusting the claim—including ignoring clear evidence of psychological injury and delaying IRB responses for over a year—to be imprudent, inflexible, and unyielding.

Costs were not ordered.

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

The respondent denied the benefits, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The applicant claimed chronic pain and psychological injuries warranted removal from the MIG.

The Tribunal found the medical evidence did not support the applicant's claims of chronic pain with functional impairment or psychological injury.

The applicant was held within the MIG, and the disputed treatment plans, award, and interest were denied.

The appellant appealed a decision by Tarion Warranty Corporation denying her claims for major structural defects relating to brick veneer and roof assembly.

The appellant argued that both claims should have been assessed under second-year warranty criteria rather than major structural defect criteria, and that Tarion failed to assess the roof claim entirely.

The Tribunal held that it lacked the authority to reopen the second-year claims process or to order Tarion to assess a major structural defect claim using second-year criteria.

However, the Tribunal found that Tarion had failed to assess the specific roof condensation claim listed in the appellant's form, mistakenly believing it had been addressed under a different item.

The Tribunal ordered Tarion to conduct a conciliation and issue an assessment report for the roof claim under the major structural defect warranty.

The respondent insurer requested a reconsideration of a Tribunal decision that ordered payment of disputed treatment plans due to defective denial notices under s. 38(8) of the Schedule.

The insurer argued the Tribunal breached procedural fairness by relying on un-cited binding case law, and erred in law by not applying the 260-week limitation period under s. 20(1)(a) to the s. 38(11) remedy.

The Tribunal dismissed the request, finding no breach of procedural fairness as parties are expected to know binding law, and holding that the consumer protection mandate of the Schedule dictates that s. 20(1)(a) does not constrain the specific remedial provisions of s. 38(11).

The applicant sought entitlement to various treatment plans for chiropractic services, yoga therapy, assistive devices, and a nutritional assessment following a motor vehicle accident.

The Licence Appeal Tribunal dismissed the application, finding that the applicant failed to meet his evidentiary burden.

Specifically, the applicant failed to provide copies of the disputed treatment plans, making it impossible to determine the exact services, goals, and costs proposed.

The Tribunal also found insufficient medical evidence to support the reasonableness and necessity of the claimed benefits.

Claims for interest and a special award were consequently dismissed.

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

The respondent denied the benefits, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found that the applicant demonstrated chronic pain syndrome with functional impairment, warranting removal from the MIG.

The Tribunal approved the disputed treatment plans for physiotherapy and a psychological assessment, finding them reasonable and necessary based on the medical evidence.

The claim for a special award under s. 10 of Reg. 664 was dismissed as the respondent's conduct did not rise to the level of being unreasonable, but interest was awarded on overdue payments.

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

The Tribunal found that the Applicant was barred from disputing several treatment plans because she failed to apply within the two-year limitation period, noting the insurer's denials were compliant with the requirements in Smith v. Co-operators.

For the remaining treatment plans, the Tribunal dismissed the claims, finding the Applicant failed to provide contemporaneous medical evidence demonstrating that the proposed multidisciplinary, neurological, physiotherapy, and psychological treatments were reasonable and necessary.

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

The respondent denied the benefits, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The matter proceeded to a written hearing, but the applicant failed to file any submissions or evidence after her representative withdrew.

The Tribunal found the applicant failed to meet her burden to prove her injuries warranted removal from the MIG or that she was entitled to the disputed treatment plans.

Additionally, the Tribunal ordered the applicant to repay $400.00 in income replacement benefits, as she had returned to work during the period for which the benefits were paid and the respondent had provided proper notice of the overpayment.

The applicant was involved in a motor vehicle accident and sought statutory accident benefits.

The respondent denied the benefits, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The applicant applied to the Licence Appeal Tribunal for various treatment plans, including psychological and chronic pain assessments, and physiotherapy.

The Tribunal found that the applicant failed to meet the onus of proving his injuries warranted removal from the MIG.

The applicant provided minimal evidence of chronic pain causing functional impairment, no evidence of a pre-existing condition precluding recovery, and no objective evidence of a psychological injury.

Consequently, the applicant remained subject to the $3,500 MIG limit, and the application was dismissed.

The minor applicant was involved in a motor vehicle accident and sought statutory accident benefits.

The respondent insurer denied benefits, arguing the application was delayed without a reasonable explanation.

The Tribunal found that the applicant, being seven years old at the time of the accident and reliant on her parents, had a reasonable explanation for the delay.

The Tribunal noted the applicant's minority status, her parents' language barriers, and the lack of significant prejudice to the insurer.

The applicant was permitted to proceed with her claim.