David J. Evans

The applicant sought income replacement benefits, medical benefits for physiotherapy and massage therapy, and the cost of various assessments following a motor vehicle accident.

The arbitrator dismissed all claims, finding the applicant entirely lacking in credibility due to numerous contradictions regarding his pre-accident health, employment duties, living arrangements, and the accident itself.

Surveillance evidence and independent medical examinations demonstrated significant symptom magnification and inconsistent effort.

The arbitrator concluded the applicant did not suffer a substantial inability to perform his employment tasks and that the claimed medical treatments and assessments were not reasonable or necessary.

The applicant was injured in a motor vehicle accident and received statutory accident benefits from the insurer.

The insurer terminated the benefits and the parties signed a release.

The applicant later applied for arbitration, arguing the release was ineffective and the termination notice was invalid.

The arbitrator found that the release did not meet the regulatory requirements and was therefore not a full and final settlement.

Furthermore, the termination notice did not constitute a valid refusal under the Smith test because it failed to adequately inform the applicant of the dispute resolution process.

As a result, the limitation period never commenced, and the applicant's claim was not time-barred.

The Applicant was injured in a motor vehicle accident and applied for statutory accident benefits, including housekeeping.

The Insurer scheduled an insurer's examination (IE) for the housekeeping claim, which the Applicant failed to attend.

The Insurer argued the Applicant was precluded from proceeding to arbitration on all issues under section 50 of the Schedule.

The Arbitrator held that the exclusion under section 50 would only apply to the housekeeping claim, not all claims.

Furthermore, the Arbitrator found the Insurer's notice of the IE was fatally flawed because it failed to clearly set out the consequences of non-attendance and the Insurer failed to make reasonable efforts to schedule the examination at a convenient time.

Therefore, the Applicant was not precluded from proceeding to arbitration on any issues.

The applicant was injured in a motor vehicle accident and received income replacement benefits for 104 weeks.

The insurer terminated benefits on the basis that the applicant did not meet the post-104 week test of suffering a complete inability to engage in any suitable employment.

The arbitrator found that the applicant failed to make a bona fide effort to find suitable alternative employment and intentionally limited his job search.

Furthermore, surveillance evidence and inconsistencies in the applicant's testimony severely undermined his credibility regarding his alleged chronic pain and deterioration.

The arbitrator concluded that the applicant failed to establish a prima facie case of total disability and that the insurer had identified suitable alternative occupations.

The application for ongoing income replacement benefits was dismissed.

The Applicant was injured in a motor vehicle accident and applied for statutory accident benefits.

He initially represented to the insurer that he was unemployed at the time of the accident, allegedly to avoid termination of his WSIB benefits.

He later claimed he was employed and sought income replacement benefits.

The insurer denied the benefits, arguing the Applicant wilfully made a material misrepresentation.

The Arbitrator found that employment status is a fundamental aspect of an application for weekly benefits and is therefore a material fact.

The Arbitrator concluded that the Applicant is precluded from receiving income replacement benefits pursuant to section 48 of the Schedule due to his wilful misrepresentation.

The applicant was injured in a motor vehicle accident and sought payment for the costs of various medical assessments and treatment plans from a rehabilitation centre under section 24 of the Statutory Accident Benefits Schedule.

The insurer denied the claims.

The arbitrator found that the applicant had withdrawn her treatment plans, breaking the link between the assessments and her claim for accident benefits.

Furthermore, the arbitrator found the assessments to be unreasonable, duplicative, or prepared by individuals not qualified as health professionals.

The claim for examination expenses was dismissed in its entirety.

The applicant sought interim income replacement benefits following a motor vehicle accident.

The insurer had terminated her benefits, and the applicant argued she was entitled to interim benefits based solely on financial need and the insurer's defective termination notice.

The arbitrator dismissed the motion, holding that the test for interim benefits requires both financial urgency and a prima facie case for entitlement based on health.

Because the applicant elected to proceed without providing medical evidence, she failed to establish a prima facie case.

The arbitrator also rejected the argument that a defective termination notice created a positive obligation to pay benefits on the merits.

Following a settlement of a statutory accident benefits claim for $85,000 plus expenses, the parties could not agree on the quantum of expenses.

The applicant claimed approximately $33,000 in legal fees and disbursements.

The arbitrator assessed the expenses by applying the criteria in the Dispute Resolution Practice Code and the Expense Regulation.

The arbitrator reduced the hours claimed due to late delivery of medical reports and time thrown away by a change of counsel, but allowed the maximum hourly rate of $150 for the applicant's senior counsel due to the excellent result achieved.

The insurer was ordered to pay $20,913.68 in expenses.

The applicant fractured his hand when a trailer he was manually pulling to hook up to his van rolled and crushed his hand against a wall.

The insurer denied statutory accident benefits, arguing the incident was not an 'automobile accident' because the trailer was not an 'automobile' and the slip-and-fall was an intervening cause.

The arbitrator found that the trailer was being 'used in connection with' the van, bringing it within the policy's definition of an automobile.

The arbitrator concluded that the applicant was involved in an automobile accident and his impairments arose directly from the use or operation of an automobile.

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

He was also convicted of assault arising from an altercation that occurred immediately prior to the accident.

The insurer terminated benefits and sought repayment, arguing the applicant was excluded under the criminal offence provisions of the Statutory Accident Benefits Schedule.

The arbitrator found that the assault continued at the time of the accident, triggering the exclusion.

The arbitrator rejected the applicant's arguments of waiver and estoppel, ordering the applicant to repay $6,487.19 in benefits to the insurer.

The applicant sought expenses incurred at an assessment hearing following a decision on statutory accident benefits.

The insurer did not object to the recalculated GST on disbursements, which was allowed at $711.60.

The arbitrator found the applicant was entitled to expenses for the assessment hearing because he was successful on the major dispute regarding his counsel's hourly rate.

However, the hours claimed were reduced as excessive for a straightforward issue, and photocopying disbursements for well-known cases were denied.

The applicant was awarded $481.50 for assessment hearing expenses.

The applicant was injured in a motor vehicle accident and applied for statutory accident benefits from Zurich.

Zurich brought a preliminary motion arguing it had an absolute defence under the Disputes Between Insurers Regulation, alleging that another insurer, Lumbermens, was the first to receive a completed application for benefits.

The arbitrator found that Zurich's evidence was based on unsupported hearsay, while documentary evidence from Lumbermens refuted the claim that it had received an application.

The arbitrator concluded that Zurich received the first completed application and dismissed the motion, allowing the applicant to proceed to arbitration against Zurich.

The applicant sought expenses following a successful arbitration for statutory accident benefits.

The insurer disputed the hourly rate, the total hours claimed by the applicant's counsel, and certain disbursements.

The arbitrator awarded the maximum hourly rate of $150 for the applicant's experienced counsel, finding the case complex and vigorously pursued.

The arbitrator allowed most of the claimed hours and disbursements, resulting in a total expense award of $36,098.46, less amounts already paid.

The applicant sought statutory accident benefits, including caregiver benefits and medical expenses, alleging that a 1994 motor vehicle accident caused a disc herniation in 1996.

The arbitrator found that the applicant's evidence regarding the onset of her disability was unsupported by contemporary medical documentation, which indicated the disability began at the time of the herniation, more than two years after the accident.

Furthermore, expert medical evidence failed to establish a causal link between the 1994 accident and the 1996 disc herniation.

All claims for benefits, expenses, and a special award were denied.

The applicant was injured in a motor vehicle accident and applied for statutory accident benefits from the insurer.

The insurer refused to pay benefits on the basis that the applicant provided late notice of his intention to claim benefits.

The applicant argued that his medical condition and reliance on counsel provided a reasonable explanation for the delay.

The arbitrator found that while the medical explanation was reasonable up until the time the applicant retained counsel, the simple reliance on counsel thereafter did not constitute a reasonable explanation.

The applicant was therefore precluded from proceeding to arbitration.

The applicants applied for statutory accident benefits following a motor vehicle accident.

The insurer requested that the applicants attend insurer examinations and produce certain documents, which the applicants refused.

On a preliminary issue, the arbitrator found that the insurer had a prima facie case for the requested examinations and that the applicants failed to make themselves reasonably available.

The arbitration hearings were adjourned until the applicants attend the examinations.

No production orders were made at this time, pending further submissions from the parties.

The applicant was injured in a motor vehicle accident and received statutory accident benefits from the insurer.

She signed a Full and Final Release in December 1998.

Two years later, a rehabilitation centre commenced mediation and arbitration proceedings in her name for unpaid transportation and assessment expenses.

The arbitrator held that the applicant was barred from proceeding by the clear terms of the release, which excluded the disputed expenses.

Furthermore, the claim for the assessment fee was barred by the two-year limitation period.

The arbitrator declined to find the arbitration frivolous or vexatious under s. 282(11.2) of the Insurance Act, but ordered the applicant to pay the insurer's expenses due to her lack of success and the hindrance caused by her representative's conduct.

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

The insurer sought to compel the applicant to attend four insurer's examinations (neurological, physiatry, psychological, and functional abilities) pursuant to section 42 of the Statutory Accident Benefits Schedule.

The arbitrator found that the neurological and psychological evaluations were reasonably necessary due to new medical information provided by the applicant's experts.

However, the physiatry and functional abilities evaluations were deemed unreasonable as they were either duplicative of previous Designated Assessment Centre (DAC) assessments or lacked sufficient justification.

The Arbitrator issued a correction to a Decision on Expenses dated August 24, 2001.

The correction amended the date of an earlier decision referenced in the first paragraph from September 20, 2000, to September 28, 2000.

The insurer brought a motion on preliminary issues regarding the format of a pre-hearing discussion and the applicant's failure to attend insurer examinations.

The self-represented applicant requested a teleconference for convenience, while the insurer insisted on an in-person meeting to better assess credibility and facilitate settlement.

The arbitrator ordered the pre-hearing to be held face-to-face, noting that in-person discussions are generally more fruitful for settlement and the applicant lived a reasonable distance from the Commission.

The issue regarding the insurer examinations was withdrawn after the applicant clarified he was only claiming benefits up to a specific date.