4 total
Application for accident benefits dismissed; applicant failed to establish chronic pain warranting removal from the Minor Injury Guideline.
The applicant sought statutory accident benefits following a motor vehicle accident.
The respondent denied a treatment plan for $1,384.70 on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG) and the $3,500 limit had been exhausted.
The applicant argued that she suffered from chronic pain and a partial ACL tear, which should remove her from the MIG.
The Tribunal found that the applicant's injuries were predominantly minor, noting that partial tears are included in the MIG definition of a strain.
Applying the AMA Guides 6th Edition criteria, the Tribunal concluded the applicant failed to establish chronic pain with functional impairment.
The application was dismissed.
Appeal dismissed; applicant's arbitrary claim to the Fund lacked sufficient nexus to trigger payment obligation.
The applicant was injured in a motor vehicle accident and applied for statutory accident benefits from the Motor Vehicle Accident Claims Fund, despite a police report indicating the vehicle he was in was insured by Wawanesa.
The Fund refused to pay, arguing the application was incomplete without the police report and there was an insufficient nexus.
The arbitrator found the application was complete but agreed there was an insufficient nexus because the applicant's choice to apply to the Fund was arbitrary, as he took no steps to determine if other insurance was available.
The Director's Delegate dismissed the appeals by the applicant and Wawanesa, confirming that an applicant must have some basis for believing coverage is unavailable elsewhere before applying to the Fund as the insurer of last resort.
Coverage dispute regarding whether applicant is an 'insured' must be decided by private arbitrator in priorities dispute.
The applicant was injured in a motor vehicle accident and applied to the insurer for statutory accident benefits.
The insurer denied coverage and initiated a priorities dispute, arguing another insurer was responsible.
The insurer sought a preliminary determination at the Financial Services Commission of Ontario (FSCO) on whether the applicant was an 'insured' under the Schedule.
The arbitrator held that distinguishing between coverage disputes and priority disputes is artificial and contrary to the legislative scheme.
The issue of whether the applicant is an insured must be determined by a private arbitrator as part of the priorities dispute under O. Reg. 283/95, not by a FSCO arbitrator.
Application for statutory accident benefits dismissed due to unreliable evidence and surveillance contradicting claimed impairments.
The Applicant was injured in a motor vehicle accident and sought statutory accident benefits for housekeeping, attendant care, and medical expenses.
The Insurer denied the claims based on various medical and functional assessments, as well as surveillance evidence showing the Applicant performing physical tasks without apparent difficulty.
The Arbitrator found the Applicant's evidence regarding his pre- and post-accident housekeeping and attendant care needs to be unreliable and inconsistent.
The Arbitrator concluded that the Applicant failed to establish a substantial inability to perform his pre-accident housekeeping tasks, did not prove he incurred the claimed attendant care expenses, and failed to show that the additional medical treatment was reasonable and necessary.
The application for benefits was dismissed.
