The claimant had an ongoing FSCO arbitration addressing the same benefit in dispute. Adjudicator Watt granted an order on consent dismissing the LAT application.
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Category: Jurisdiction
The claimant had an ongoing FSCO arbitration addressing the same benefit in dispute. Adjudicator Watt granted an order on consent dismissing the LAT application.
The claimant had an ongoing FSCO arbitration addressing the same benefit in dispute. Adjudicator Watt granted an order on consent dismissing the LAT application.
The claimant sought entitlement to attendant care benefits. The insurer resisted the application for arbitration and asserted that the determination was already decided in a previous FSCO decision. Adjudicator S.F. Mather determined that the claimant’s claim before the LAT was not the same by virtue of the dates claimed. Additionally, Adjudicator Mather ruled that the FSCO decision did not make a final determination regarding attendant care benefits in the future. Indeed, it was noted that the submission of a new Form 1 would allow the claimant to dispute the denial of the insurer.
The claimant sought entitlement to attendant care benefits provided by her husband (a fertility physician) and the cost of an in-home assessment. The insurer denied that the claimant had “incurred” any attendant care services and further denied that any attendant care services were reasonable and necessary beyond June 2016. The claimant responded that the insurer was estopped from denying payment of attendant care benefits because it had already accepted that services had been “incurred” in earlier months by services provided by her husband. Adjudicator Paluch considered all three elements of the “incurred” definition and concluded that none of the requirements had been met. First, he held that claimant had not proven on a balance of probabilities that her husband had provided the services claimed, and that the expense forms were not an accurate reflection of services that were actually provided. Second, he held that the claimant did not have any legal obligation to pay her husband for any services he may have provided. Third, he held that the claimant’s husband was not a professional service provider (his regular employment did not concern any tasks that were contained in a Form 1), and that the service provider had not proven that an economic loss had been sustained by providing services to the claimant. In particular, Adjudicator Paluch was critical of the service provider not providing any records of lost income or time from work, and instead simply providing oral testimony. Finally, Adjudicator Paluch concluded that the LAT did not have jurisdiction to administer the rules of equity, as it could only grant remedies set out in its enabling statute. Adjudicator Baluch denied the claim for attendant care benefits and the in-home assessment cost.
The claimant sought entitlement to a medical treatment plan. In addition to the issues outlined in the Case Conference Order, the claimant also sought a lump sum payment of $35,000.00 for 5 years of future medical treatment. Adjudicator Truong noted that issues not codified by the Case Conference Order were not properly before the Tribunal and therefore could not be determined. On review of the medical evidence, the treatment plan in dispute was found not reasonable and necessary. It was noted that a treatment plan alone is not sufficient evidence to establish entitlement – corroborating evidence is also required.
The claimant was a pedestrian knockdown in Ontario. She applied for and received accident benefits, including IRBs, under Quebec’s Quebec Societe de l’assurance automobile. Her IRBs were terminated 11 months post-accident and she did not appeal the decision. She then applied for IRBs in Ontario. The insurer paid IRBs and terminated benefits up to and slightly beyond the 104-week cut-off. The insurer raised a preliminary issue stating that the claimant was not entitled to IRBs as she was a Quebec resident at the date of loss and entitled to benefits under Quebec’s insurance regime. Adjudicator Pay found the claimant was entitled to pursue an IRB claim in Ontario. Adjudicator Pay noted that the Ontario regime was designed with consumer protection in mind, and the Schedule did not contemplate residency of the insured other than for accidents outside Ontario. Therefore, if the accident occurred in Ontario, the claimant has access to the SABS.
The claimant sought entitlement to a number of medical benefits. Additionally, the claimant sought entitlement to medical benefits generally, in the sum of $10,000,000.00. The insurer resisted the claims and asserted the matter was dealt with at FSCO. The insurer raised a preliminary issue to that effect, to which the claimant was not prepared for given confusing correspondence with the LAT. As a result, the claimant sought an adjournment. Adjudicator Chloe Lester granted the adjournment.
A completed OCF-3 was submitted; the claimant was said to have not met the test for NEBs. An OCF-10 was submitted whereby the claimant elected NEBs. The insurer sought a preliminary hearing to have the claimant’s claim for NEBs dismissed without a hearing. Adjudicator Pay concluded that the claimant was still entitled to pursue a claim for NEBs despite the original OCF-3 not supporting NEBs.
The insurer brought a motion to dismiss a claim on the basis of the claimant’s non-attendance at IEs and due to the overlap with issues previously before FSCO. The IE notices were deemed insufficient; therefore, the insurer’s s. 55 defence did not apply. The claimant was not barred from proceeding with the issues that were originally before FSCO as there was never a determination on those issues, which were withdrawn rather than dismissed.