The claimant was a fetus in utero at the time of the accident and born prematurely four days after the accident. She was diagnosed with cerebral palsy as a result of her premature birth. The insurer initially paid accident benefits based on a medical opinion, but subsequently questioned causation based on an opinion of an obstetrician. While the claimant filed applications regarding entitlement to attendant care benefits and other accident benefits, the insurer filed the subject LAT for a determination on the causation issue. The claimant argued that the limitation period applied to the insurer changing its position on causation. All of the applications were consolidated into a single dispute and a preliminary motion was heard to decide whether the insurer could change its opinion on causation two years after the accident in reliance on the report of its obstetrician. Adjudicator Grant concluded that the insurer was not precluded from arguing causation at the subsequent hearing. There was no evidence of waiver because the insurer would have had to be shown to have full knowledge of the facts and choose not to assert its right to deny a benefit. Instead, the insurer acted appropriately by approving benefits while it sought to obtain an expert opinion on causation. The insurer’s approval of attendant care benefits did not waive its right to revisit causation and conduct future IEs. Further, the limitation period did not apply to an insurer’s defences. Section 56 only applied to denials of benefits. The claimant also argued that the obstetrician’s report should be excluded because it was obtained by the insurer’s legal counsel. Adjudicator Grant rejected the argument, reasoning that the insurer had provided the claimant with an IE notice and its counsel was simply acting as an agent.
The claimant was involved in a motor vehicle accident in Alberta. At the time of the accident, he had an insurance policy that was sold in Alberta and was driving a vehicle that was registered in Alberta. He received benefits pursuant to the Alberta Automobile Accident Insurance Benefits and then claimed benefits under the SABS. The insurer refused to pay benefits under the SABS because the claimant was insured under an Alberta policy and had an Alberta address and driver’s licence. The issue at the LAT hearing was whether the Tribunal had jurisdiction to hear the dispute. Adjudicator Norris found that Part V of the Insurance Act did not apply to the claimant’s policy, therefore the claimant was not entitled to file an application pursuant to section 280(2) of the Insurance Act, and the LAT did not have jurisdiction to hear the matter.
On the eve of the hearing, the claimant brought various motions to add the insurer’s counsel as a witness, for production of records from the IE facilities, to hold the insurer’s counsel in contempt, and to adjourn the hearing. The motions all related to the claimant’s counsel’s position that the IE assessors had violated PIPEDA by not providing records or providing incomplete records. Vice Chair Marzinotto dismissed the motions, and noted that the claimant did have some of the requested records in her possession, that the motion was not timely as it was brought only two weeks before the hearing, that the insurer’s counsel had not acted improperly (and had, in fact, attempted to assist in obtaining the requested records), and that the insurer’s counsel was not a necessary witness at the hearing. Vice Chair Marzinotto also noted that any allegations of PIPEDA violations could not be addressed by the LAT. The hearing was adjourned as a result of the claimant’s late motion.
The insurer argued that the claimant could not proceed with a LAT hearing because of his failure to attend an IE. The claimant argued that the IE notice was deficient and that the IE request was not reasonable. Adjudicator Punyarthi held that the IE request was reasonable and that the insurer was not required to provide a copy of the contract or retainer between it and the IE facility, or prove which records were given to the IE facility. The request for an IE was also reasonable as the last prior IEs had been performed two years prior and the insurer had to determine whether the MIG still applied to the claimant’s injuries. The adjudicator held that a paper review would not have been sufficient for the insurer at the time the IE was requested, and the insurer would have been prejudiced if a hearing were to proceed. Finally, Adjudicator Punyarthi rejected the claimant’s position that the Tribunal had the authority to reprimand the insurer for a breach of PIPEDA or for an alleged breach of the duty of good faith.
The claimant sought judicial review of the Tribunal’s decision that it did not have jurisdiction to award interim benefits. Before the hearing, the claimant and the insurer settled the claim on a full and final basis. The claimant argued that the Court should nevertheless make a determination on the matter. The Court dismissed the judicial review on the grounds that it was moot, but wrote that the Tribunal’s earlier decision was not binding on any other adjudicator.
The insurer had initially treated the claimant with the MIG, but removed her from the MIG following receipt of medical records. Despite being removed from the MIG, the claimant sought an order that the MIG was unconstitutional. Adjudicator Boyce held that the Tribunal did not have jurisdiction to address the Charter challenge because the dispute regarding the MIG was moot following the insurer’s decision to remove the claimant from the MIG.
The claimant sought payment of $11,865 for hockey training. The claimant had been actively engage in competitive hockey, and sought to regain physical strength and skill to return to pursue her goal of playing NCAA hockey. Adjudicator Parish dismissed the claim. She held that the claimant failed to comply with section 38(2) by incurring the cost before submitting a treatment plan, and that none of the exceptions to 38(2) applied. She also held that the Tribunal did not have jurisdiction to grant relief from forfeiture, but also, that it would not apply to the facts of the case.
The insurer suspended the claimant’s entitlement to IRBs. The claimant applied to the LAT. Before the Case Conference, the insurer reinstated the IRBs. The insurer argued that the LAT did not have jurisdiction to consider the claim for IRBs. Adjudicator Kepman concluded that the Tribunal did not have jurisdiction under the Insurance Act to consider the claim, since all IRBs plus interest had been paid to the claimant. However, she did consider the claim for a special award, and concluded that the insurer had not acted unreasonably in its adjusting of the claim.
The claimant sought reconsideration of the Tribunal’s decision that it could not adjudicate or enforce a purported full and final settlement. Vice Chair Hunter granted the reconsideration and held that the Tribunal did have a more robust jurisdiction under the Insurance Act than simply deciding entitlement to benefits. Whether an accident benefits settlement had been reached fell within the Tribunal’s jurisdiction.
The claimant applied to the LAT for IRBs. The insurer approved entitlement eight days before the hearing. The claimant sought an order from the Tribunal that she was entitled to ongoing IRBs; the insurer argued that because there was no longer a dispute, the Tribunal did not have jurisdiction. Adjudicator Gosio held that once the insurer agreed to pay IRBs, the Tribunal lost jurisdiction to adjudicate the issue, and that sections 280 and 281 did not permit the Tribunal to make an order once a dispute had been resolved.