Peter Durant

The applicant was injured in a motor vehicle accident and sought payment for three treatment plans (OCF-18s) for chiropractic and psychological services, which the respondent insurer denied in whole or in part.

The Tribunal found that the applicant failed to prove the balances of the first two treatment plans were reasonable and necessary, as they exceeded maximum guideline amounts or lacked supporting evidence for report writing fees.

However, the Tribunal partially approved the third treatment plan for chiropractic, massage, and physiotherapy, finding it reasonable and necessary based on consistent medical evidence of ongoing pain and functional improvement.

Interest was awarded on the overdue benefits.

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 parties both sought reconsideration of a previous Licence Appeal Tribunal decision regarding statutory accident benefits following a motor vehicle accident.

The respondent sought to overturn the award of an income replacement benefit based on newly obtained medical records and a CPP-D denial letter.

The adjudicator dismissed the respondent's request, finding the new records did not alter the conclusion that the applicant suffered serious cognitive and psychological impairments.

The applicant sought reconsideration to approve previously denied treatment plans, providing two of the three missing plans.

The adjudicator granted the applicant's request in part, approving the physiotherapy plan and portions of the psychological services plan, but upheld the denial of the psychological assessment as that plan was still not provided.

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

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

The adjudicator found that the applicant's physical and psychological injuries were predominantly minor and that she failed to provide medical evidence demonstrating impairments that would remove her from the MIG.

Consequently, the disputed treatment plans were not payable, and the application was dismissed.

The applicant was struck by a vehicle as a pedestrian and sought income replacement and medical benefits.

The Tribunal found the applicant was entitled to ongoing income replacement benefits beyond the 104-week mark, as his accident-related psychological and cognitive impairments rendered him completely unable to engage in any employment for which he was reasonably suited.

The claims for medical benefits were dismissed because the applicant failed to provide the required treatment plans (OCF-18s) to establish that the treatments were reasonable and necessary.

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

The respondent denied the claims, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG) and were subject to the $3,500 limit.

The applicant argued his injuries went beyond the MIG due to physical and psychological impairments, as well as chronic pain.

The Tribunal found that the medical evidence supported soft tissue injuries consistent with the MIG, and there was insufficient evidence of psychological impairment or chronic pain affecting functionality.

The application was dismissed as the injuries were predominantly minor.

The applicant was struck by a taxi as a pedestrian, sustaining severe facial injuries.

She sought statutory accident benefits for septorhinoplasty and scar revision, which the insurer denied.

The insurer raised a preliminary issue that the appeal was statute-barred under s. 56 of the Statutory Accident Benefits Schedule.

The Tribunal found the appeal was not statute-barred because the insurer's subsequent reconsideration and second denial notice rendered the initial denial equivocal, resetting the limitation period.

On the substantive issues, the Tribunal found the proposed treatments were reasonable and necessary, preferring the evidence of the applicant's plastic surgeon over the insurer's expert.

The appeal was allowed and the disputed benefits were ordered payable with interest.

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

The respondent denied funding for attendant care benefits and various treatment plans, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The Tribunal found that the applicant's injuries, particularly chronic pain, removed him from the MIG.

The Tribunal partially approved the treatment plans for physical therapy and assistive devices, and approved the cost of a chronic pain assessment.

However, claims for attendant care benefits, psychological treatment, psychological assessment, and a special award were dismissed.

Interest was awarded on overdue payments.

The applicants sought accident benefits from the insurer following a motor vehicle accident.

The matter proceeded to an arbitration hearing.

Neither the applicants nor their representative attended the hearing, despite receiving notice and having a prior adjournment request denied.

The arbitrator proceeded in their absence and dismissed the applications for arbitration because the applicants failed to meet their burden of proof.

The arbitrator ordered the applicants to pay the insurer's expenses, finding their conduct in failing to pursue the applications and failing to notify the insurer of their non-attendance unnecessarily lengthened the proceeding.

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

Her legal representatives withdrew prior to the hearing.

The applicant failed to attend the rescheduled arbitration hearing.

The arbitrator dismissed the applicant's claims for failing to meet the burden of proof.

The insurer was awarded $1,500 in expenses due to the applicant's failure to participate, which prolonged the proceedings.

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

After her legal representatives withdrew due to a breakdown in the solicitor-client relationship, the applicant failed to attend the scheduled arbitration hearing despite being given notice and an adjournment.

The arbitrator dismissed the claims because the applicant failed to participate and meet her burden of proof.

The insurer was awarded $1,500 in expenses for legal fees and obtaining an OHIP summary, but its request for reimbursement of a $3,000 assessment fee was denied.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits, including non-earner, attendant care, housekeeping, and medical benefits, which the insurer denied.

The arbitrator found the applicant credible and concluded she suffered soft-tissue injuries that continuously prevented her from engaging in substantially all of her pre-accident activities, entitling her to non-earner benefits.

The arbitrator also awarded attendant care benefits for a limited period at a reduced rate, and housekeeping benefits for the claimed period, less a two-week vacation.

The insurer was ordered to pay for an approved treatment plan and two assessments, along with a special award for unreasonably withholding payment for the assessments, plus interest.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits, including non-earner, attendant care, housekeeping, and medical benefits.

The arbitrator found significant credibility issues with the applicant's evidence, noting inconsistencies and symptom magnification.

The claims for non-earner and housekeeping benefits were dismissed as the applicant failed to establish a complete or substantial inability to perform his pre-accident activities.

Attendant care benefits were granted for a limited one-month period.

The arbitrator also awarded the cost of an attendant care assessment, one treatment plan, and a special award due to the insurer's unreasonable delay in paying for the assessment.

The insurer appealed an arbitrator's decision allowing the insured to proceed to arbitration regarding the stoppage of income replacement benefits despite the expiry of the two-year limitation period.

The Director's Delegate upheld the arbitrator's finding that the Notice of Stoppage (OCF-17) was invalid because it misleadingly indicated that requesting a Designated Assessment Centre (DAC) assessment was a mandatory prerequisite to disputing the stoppage.

Because the notice failed to properly inform the insured of the dispute resolution process, it did not constitute a clear and unequivocal refusal, and the limitation period was never triggered.

The insurer appealed a preliminary arbitration decision which found that the insured was not precluded from proceeding to arbitration despite the expiry of the two-year limitation period.

The arbitrator had ruled that the termination form (OCF-17) was confusing and did not properly commence the limitation period.

The Director's Delegate acknowledged the appeal, finding that the issue of whether an approved form was insufficient to commence the limitation period was novel and of great importance, and that the insurer raised bona fide legal issues.

The applicant was injured in a motor vehicle accident and received income replacement benefits until the insurer terminated them using an OCF-17 form.

The insurer argued the applicant was barred from proceeding to arbitration because the two-year limitation period had expired.

The arbitrator found that the OCF-17 form used by the insurer was confusing and did not comply with the Statutory Accident Benefits Schedule or the Supreme Court's decision in Smith v. Co-operators.

Specifically, the form misleadingly suggested that a Designated Assessment Centre (DAC) assessment was mandatory to dispute the stoppage of benefits.

As the notice was invalid, the limitation period did not begin to run, and the applicant was permitted to proceed to arbitration.