Sharon MacKay

The applicant sought a medical benefit of $1,417.48 for a physiotherapy treatment plan following a motor vehicle accident.

The respondent insurer denied the claim, arguing the applicant's shoulder injury was not caused by the accident.

The Tribunal reviewed the medical evidence, noting the applicant did not report shoulder issues until nearly eleven months post-accident and that a neurologist attributed the shoulder issues to a pre-existing contracture from prior bilateral prophylactic mastectomies.

The Tribunal found the shoulder injury was not accident-related and dismissed the application for the treatment plan and interest.

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

The insurer stopped the benefits and sent multiple Explanation of Benefits (OCF-9) forms.

The insurer argued the applicant's claim for arbitration was statute-barred as it was commenced more than two years after the refusal.

The arbitrator found that the insurer's refusal was not clear and unequivocal, as it emphasized the rebuttal process without adequately informing the applicant of other dispute resolution steps like mediation and arbitration.

Therefore, the limitation period was not triggered, and the applicant's claim was not statute-barred.