Sharla Bandoquillo

The moving party, acting self-represented, brought a motion for leave to appeal a lower court decision dated December 10, 2024.

The Divisional Court reviewed the matter in writing.

The court dismissed the motion for leave to appeal and awarded costs to the responding parties in the fixed amount of $2,000.

The applicant was injured in a motor vehicle accident while in the course of his employment and initially elected to receive WSIB benefits.

Over 18 months later, he submitted an application for statutory accident benefits (OCF-1) to the respondent insurer.

The respondent denied the claim on the basis that the application was submitted outside the prescribed timelines.

The Licence Appeal Tribunal found that the applicant failed to provide a reasonable explanation for the delay, rejecting his argument that he was waiting to determine if his injuries met the tort threshold.

Consequently, the applicant was statute-barred from proceeding with his application for benefits, and the application was dismissed.

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

The insurer denied benefits and argued the applicant was barred from proceeding because he failed to submit the OCF-1 application within the prescribed 30-day time limit.

The Tribunal found that the applicant provided a reasonable explanation for the delay, as the insurer's correspondence regarding the interplay between WSIB benefits and accident benefits was confusing.

Although the applicant was not barred from proceeding, the Tribunal closed the file as there were no substantive issues in dispute.

The applicant, a pedestrian struck by a vehicle, sought statutory accident benefits for a catastrophic impairment assessment plan.

The respondent insurer partially approved the plan but denied funding for clinic file reviews, transportation fees, and a form fee, arguing they exceeded the $2,000 cap under section 25(5) of the Statutory Accident Benefits Schedule.

The Tribunal found that file review fees and form fees are included within the $2,000 assessment cap.

The Tribunal also found no evidence to support the claim for transportation expenses.

The application was dismissed.

The applicant sought to set aside a full and final settlement of his statutory accident benefits claim, arguing he lacked the mental capacity to enter into the agreement due to a traumatic brain injury sustained in a motor vehicle accident.

The Licence Appeal Tribunal dismissed the application, finding that the applicant failed to rebut the statutory presumption of capacity.

The Tribunal preferred contemporaneous medical and vocational evidence showing the applicant had average cognitive abilities over a capacity assessment conducted three months after the settlement.

The settlement was deemed valid as it was not rescinded within the two-day cooling-off period.

The applicant sought income replacement benefits (IRB) following a 2013 motor vehicle accident.

The respondent insurer denied the IRB claim in May 2014 after the applicant returned to work.

The applicant stopped working again in 2016 but did not dispute the IRB denial until filing a Tribunal application in March 2019, well beyond the two-year limitation period under s. 56 of the Statutory Accident Benefits Schedule.

The Tribunal found the application was statute-barred and declined to extend the limitation period under s. 7 of the Licence Appeal Tribunal Act, 1999, noting the lack of a bona fide intention to appeal within the time limit, the excessive 34-month delay, prejudice to the respondent, and lack of merit.

The applicant sought funding for a psychiatric assessment and occupational therapy assessments as part of a catastrophic impairment determination following a motor vehicle accident.

The respondent denied the psychiatric assessment as duplicative of an approved psychological assessment, and disputed the number of occupational therapy assessments.

The Tribunal found the psychiatric assessment was reasonable and necessary because the psychological assessment was never performed, but capped the cost at $2,000.00 under the Schedule.

The Tribunal also found the applicant was entitled to two occupational therapy assessments, capped at $2,000.00 each.

The applicant was awarded interest on the overdue amounts but denied an award under O. Reg. 664, as the respondent's denials were not unreasonable.

The applicant was injured in a motor vehicle accident and sought a determination of catastrophic impairment under the Statutory Accident Benefits Schedule based on a spinal cord injury.

The respondent denied the designation, arguing that the applicant's ASIA Impairment Scale grade was not yet "permanent" because the injury had the potential to improve over the initial 18-24 months.

The adjudicator found that the applicant met the definition of catastrophic impairment, noting that her ASIA Impairment Scale score of "D" satisfied the criteria and there was no evidence she would improve to a normal "E" score.

The adjudicator rejected the respondent's argument that a 24-month waiting period was required, as paragraph 1 of section 3.1(1) contains no such temporal requirement.

The appellant insurer appealed an arbitrator's decision that the denial of the respondent's caregiver benefit was invalid and that she was entitled to elect her preferred weekly benefit.

The insurer argued that the OCF-1 application form constituted an application for all weekly benefits, allowing it to deny all benefits without an election, relying on recent case law.

The Director's Delegate dismissed the appeal, finding that the arbitrator correctly distinguished the case law because the insurer had actual knowledge that the respondent might qualify for more than one benefit, triggering the election requirement under section 36(2) of the Statutory Accident Benefits Schedule.

Because the insurer failed to provide the required election form, the limitation period did not commence, and the respondent could still make her election.

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

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

The applicant argued he should be removed from the MIG due to a pre-existing condition, psychological impairments, and chronic pain.

The adjudicator found insufficient evidence of a pre-existing condition that would prevent maximal recovery.

The adjudicator also rejected the psychological and chronic pain claims, noting they were based on a chiropractor's report that relied entirely on self-reporting without objective assessment or appropriate expertise.

The application was dismissed as the applicant's injuries remained within the MIG.

The applicant was injured in a motor vehicle accident and sought income replacement benefits (IRBs).

The respondent insurer terminated IRBs after initially paying them, arguing the applicant could return to her pre-accident employment as a furniture salesperson.

The Tribunal found that the applicant's physical impairments, including exacerbated pre-existing degenerative conditions, and psychological impairments rendered her substantially unable to perform the essential tasks of her employment, which included prolonged standing, walking, and lifting furniture.

The Tribunal ordered the respondent to pay the weekly IRB of $336.45 from the date of termination, plus interest.

The applicant sought additional attendant care benefits, an award for unreasonably withheld payments, and interest following a motor vehicle accident.

The Licence Appeal Tribunal found that the applicant was not entitled to additional attendant care benefits because they did not incur expenses beyond what the respondent had already paid.

However, the Tribunal found that the respondent unreasonably delayed paying the incurred attendant care invoices without explanation.

The Tribunal ordered the respondent to pay an award of $2,166.15 under section 10 of Regulation 664, representing 25% of the incurred expenses.

The claim for interest was dismissed as the service provider had waived it.

The applicant sought expenses following a successful preliminary issue hearing regarding statutory accident benefits.

The arbitrator awarded the applicant $19,629.68 in expenses, inclusive of fees, disbursements, and HST, applying a 1:4 ratio for hearing to preparation time and utilizing the legal aid hourly rate.

The applicant sought medical benefits for treatments following a motor vehicle accident.

The Licence Appeal Tribunal dismissed the application, finding that the applicant failed to prove the accident caused her impairments, which were consistent with her pre-existing arthritic and fibromyalgia conditions.

The Tribunal also rejected the applicant's procedural argument that the insurer failed to provide timely notice of its refusal to pay, finding the insurer complied with the ten-day notice requirement under the Statutory Accident Benefits Schedule.

The applicant was injured in two motor vehicle accidents and sought non-earner benefits for both.

The insurer moved to bar the appeals, arguing they were filed beyond the two-year limitation period under s. 56 of the Statutory Accident Benefits Schedule.

The Tribunal found that the appeal for the first accident was statute-barred as the denial notice was clear and unequivocal.

However, the appeal for the second accident was allowed to proceed because the insurer issued multiple, confusing denial notices with changing reasons, which misled the applicant regarding the limitation period.

The applicant's request for costs was denied.

The Applicant was injured in a motor vehicle accident and sought a determination that she sustained a catastrophic impairment due to a psychiatric disorder.

The arbitrator found that the Applicant's treating psychiatrist provided sufficient evidence of a Marked Impairment under the AMA Guidelines, satisfying the catastrophic impairment threshold.

The arbitrator also awarded a special award of $9,629.70 against the Insurer for unreasonably delaying the payment of income replacement benefits for 527 days without a valid reason, but denied a special award for medical and attendant care benefits.

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

The insurer denied caregiver benefits based on the OCF-1 application and a medical certificate, arguing the claim was now statute-barred due to the passage of the two-year limitation period.

The applicant argued the denial was invalid because she had never submitted an OCF-10 election form to choose between caregiver and non-earner benefits.

The Arbitrator found that an election was necessary under section 36 of the Schedule and that the OCF-1 alone was insufficient to constitute an election.

Because no valid election was made, the insurer's denial was invalid, and the limitation period did not begin to run.

The applicant was granted the right to elect her preferred benefit without a time limit.

The respondent insurer sought reconsideration of a Licence Appeal Tribunal decision that allowed the applicant's dispute resolution application to proceed despite her refusal to attend an in-person physiatry examination.

The insurer argued the examination was necessary to assess the applicant's physical impairment for a catastrophic impairment determination.

The Executive Chair denied the reconsideration request, upholding the finding that the in-person examination was not 'reasonably necessary' under s. 44(1) of the Statutory Accident Benefits Schedule.

The Tribunal found that the insurer already had sufficient information from previous in-person assessments by an occupational therapist to conduct a paper review for the whole person impairment rating.

The applicant sought statutory accident benefits following a 2011 motor vehicle accident.

After multiple adjournments and rescheduling requests by the applicant, neither the applicant nor her representative attended the scheduled teleconference hearing on February 7, 2017.

The Tribunal issued a notice of intention to dismiss the application as abandoned.

Despite the applicant's representative blaming a former scheduling assistant for the non-attendance, the Tribunal found the explanations disingenuous and unsupported by evidence.

The Tribunal concluded that the applicant's repeated failures to attend and communicate effectively constituted an abandonment of the proceeding.

The application was dismissed without a hearing, and no costs were awarded.

The applicant sought catastrophic impairment benefits following a motor vehicle accident.

The insurer requested five in-person insurer's examinations.

The applicant agreed to three but refused to attend an in-person physiatry examination and a cardiology examination, arguing they were excessive and unreasonable.

The insurer raised a preliminary issue that the applicant was precluded from proceeding with her application due to her non-compliance.

The Tribunal found that the in-person physiatry examination was not 'reasonably necessary' under section 44 of the Schedule, as it was overly intrusive and the insurer already had sufficient information from other assessments to conduct a paper review.

The applicant was permitted to proceed with her claim.