Edward Lee

The applicant was injured in a 2007 motor vehicle accident and sought statutory accident benefits.

In 2011, the parties settled the applicant's claim for housekeeping benefits for a specific period, and a consent order was issued.

Five years later, the applicant sought to pursue further housekeeping benefits for the period following the settlement.

The arbitrator held that the Commission was functus officio, as the 2011 consent order finally disposed of the housekeeping issue and the applicant could not bring multiple applications for the same weekly benefit.

The applicant's claim was dismissed and she was ordered to pay $4,000 in expenses.

The applicant was injured in a motor vehicle accident in 2000 and commenced an arbitration proceeding at FSCO in 2002.

A settlement was reached in 2004.

Fifteen years later, the applicant sought to rescind the settlement and continue the arbitration at FSCO.

The insurer argued that under the transitional provisions of O. Reg. 664, the proceeding was extinguished at FSCO and any new application must be brought before the Licence Appeal Tribunal (LAT).

The arbitrator held that pursuant to section 22(2) of O. Reg. 664, the proceeding was extinguished at FSCO because a settlement had been entered into, and directed that either party could reapply at the LAT.

The applicant was injured in a motor vehicle accident and received income replacement benefits (IRBs) until the insurer terminated them.

Prior to the arbitration hearing, the insurer conceded the issue and paid the IRBs retroactively.

The arbitrator held that interest on the overdue IRBs began to accrue from the date they were initially terminated, as the insurer bears the consequence of a decision not to pay benefits later found owing.

The arbitrator also awarded a special award of $36,280.00, finding the insurer acted unreasonably by ignoring the conclusions of its own medical and vocational assessors, who noted that the alternative job options proposed did not provide the same remuneration as the applicant's pre-accident employment.

The insurer was ordered to pay $25,000.00 in expenses.

The appellant sought to appeal a decision of a Director's Delegate that dismissed her application to vary or revoke an earlier arbitration order regarding statutory accident benefits.

The Director's Delegate held that under the Dispute Resolution Practice Code, there is no jurisdiction for one Director's Delegate to hear an appeal of another Director's Delegate's decision.

In the alternative, the appeal would be dismissed on the merits as the appellant failed to demonstrate any error of law.

The appeal was dismissed.

Following the dismissal of the appellant's appeal of an arbitration order, the successful respondent sought its legal appeal expenses.

The Director's Delegate found that the respondent was completely successful and entitled to its expenses based on the outcome of the proceeding.

Noting that the appeal was neither long nor complex and was conducted jointly with the appellant's spouse's appeal, the Director's Delegate ordered the appellant to pay the respondent $2,500 inclusive of HST and disbursements.

The applicant sought to vary a previous arbitration order to increase his attendant care benefits to cover 24/7 care, alleging a material change in circumstances due to worsening mental and physical health following a 2003 motor vehicle accident.

The Director's Delegate found that while the applicant's mental and behavioural disorders had worsened, constituting a material change, he was far less disabled than he presented.

Relying on surveillance evidence and the respondent's occupational therapist, the Delegate concluded that 24/7 care was not reasonable or necessary, as the applicant did not pose a danger to himself or others and demonstrated independent functionality.

The Delegate increased the attendant care benefits to $1,445.75 per month to account for increased emotional support and cuing needs, but dismissed the claim for a special award.

Following the dismissal of the insurer's appeal regarding a catastrophic impairment determination, the insured sought her legal appeal expenses in the amount of $23,052.00.

The insurer submitted that $3,699.44 was reasonable.

The Director's Delegate found the issues were of average complexity and the appeal was conducted in one morning.

Based on reasonableness and average awards in similar cases, the Delegate ordered the insurer to pay $3,750.00 for appeal legal expenses, inclusive of HST and disbursements.

Following the dismissal of the appellant's appeal of an arbitration order, the respondent sought its legal appeal expenses.

The Director's Delegate found that the respondent was completely successful in resisting the appeal and was therefore entitled to its expenses based on the degree of success.

The respondent was awarded $2,500 inclusive of HST and disbursements.

The applicant sought to vary a previous arbitration order to increase his attendant care benefits to provide for 24/7 care, alleging a material change in circumstances due to worsening mental and behavioral disorders following a 2003 motor vehicle accident.

The Director's Delegate found a material change in circumstances based on a new anxiety disorder diagnosis and worsening psychological symptoms, but rejected the need for 24/7 care, relying on surveillance evidence and an occupational therapist's assessment showing the applicant was less disabled than claimed.

Attendant care benefits were increased to $1,445.75 per month to account for additional emotional support and cuing.

The claim for a special award was dismissed.

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 appellant's appeal was dismissed after being deemed abandoned, as she filed only a Notice of Appeal and requests for time extensions.

The respondent sought $4,992.40 in legal expenses for the appeal proceeding.

The Director's Delegate found the respondent's claimed expenses to be exaggerated and not commensurate with the effort required to obtain a dismissal, noting the appellant's arguments were largely generic.

The Director's Delegate ordered the appellant to pay $750.00 in legal expenses to the respondent.

The insurer appealed an arbitrator's preliminary decision finding the insured catastrophically impaired.

The insurer argued the arbitrator lacked jurisdiction to make a stand-alone catastrophic impairment determination when no specific accident benefits were claimed.

The Director's Delegate dismissed the appeal, holding that a catastrophic impairment determination is a necessary gateway issue within an arbitrator's jurisdiction under the Insurance Act.

The Delegate also found no error of law in the arbitrator's preference for the insured's expert evidence over the insurer's experts, nor in the arbitrator's application of the AMA Guides regarding the assessment of pain in mental and behavioral disorders.

The insurer appealed an arbitrator's decision finding the respondent catastrophically impaired following a motor vehicle accident.

The insurer argued the arbitrator erred in law by allowing the respondent to file expert reports after the hearing commenced and by misapplying the AMA Guides in assessing whole person impairment and mental/behavioral disorders.

The Director's Delegate dismissed the appeal, finding no error of law in the arbitrator's procedural rulings under Rule 39 of the Dispute Resolution Practice Code, as the insurer had first filed late reports.

The Delegate also upheld the arbitrator's substantive findings, concluding they were based on reasonable assessments of expert credibility and evidence.

The appellants appealed an arbitrator's decision dismissing their applications for accident benefits after they failed to attend the arbitration hearing.

The appellants argued they had not received proper notice of the hearing.

The Director's Delegate dismissed the appeal, finding that the arbitrator's determination regarding notice was a finding of fact supported by evidence from the appellants' former counsel.

As appeals under Rule 50.1 of the Dispute Resolution Practice Code are limited to questions of law, and there was evidence to support the arbitrator's finding, no error of law was made in dismissing the applications pursuant to Rule 37.9.

The appellant was injured in a 2006 motor vehicle accident and sought funding for six catastrophic impairment rebuttal reports in 2015.

The insurer paid $2,000 per report under the new SABS (2010), but the appellant claimed the balance, arguing the old SABS (1996) applied because his right to a rebuttal report had vested.

The Director's Delegate dismissed the appeal, holding that section 268(1) of the Insurance Act and the transitional provisions of the SABS clearly apply the $2,000 cap to assessments conducted after August 31, 2010, regardless of the accident date.

The concept of vested rights does not apply to statutory accident benefits.

The appellant appealed an arbitrator's decision allowing her to withdraw her application for arbitration and awarding expenses to the respondent.

The appellant failed to file written appeal submissions by the original deadline and a subsequent extended deadline.

After receiving no response to a final notice warning that the appeal would be dismissed as abandoned, the Director's Delegate dismissed the appeal.

The appellant was injured in a motor vehicle accident and received income replacement benefits (IRBs) until they were terminated.

She later received a lump sum payment for past long-term disability (LTD) benefits.

The insurer agreed to reinstate and pay past IRBs but sought to deduct the LTD lump sum from the past IRBs owed.

The Arbitrator allowed the deduction.

On appeal, the Director's Delegate rescinded the Arbitrator's decision, finding that under section 7(1) of the Statutory Accident Benefits Schedule, the insurer cannot retroactively deduct a lump sum payment of LTD benefits from past IRBs when the insured was not receiving LTD benefits during the period in question.

The appellant insurer sought a variation of an earlier order requiring it to pay ongoing income replacement benefits, which was granted but the contested issues were resolved in favour of the respondent insured.

The respondent sought expenses for the variation proceeding.

The Director's Delegate found the respondent was entirely successful on the contested issues and awarded $2,500.00 for legal fees, inclusive of disbursements and HST, after deducting disbursements for parking and mileage.

The appellant appealed an arbitrator's decision denying her claims for income replacement benefits (IRBs) and attendant care benefits following a motor vehicle accident.

The Director's Delegate upheld the arbitrator's findings that funds paid by the appellant's employer to a third-party service provider constituted post-accident income, which reduced her IRB entitlement to zero.

The Delegate also upheld the denial of attendant care benefits, as the service providers were not acting in the course of their ordinary employment.

However, the Delegate found the arbitrator erred in law by denying claims for attendant care assessments based on the threshold entitlement finding, rather than assessing if the fees were reasonable and necessary.

The appeal was allowed in part, and the issue of assessment costs was remitted to a different arbitrator.

The appellant sought legal expenses following a successful appeal that overturned an arbitrator's decision denying a special award.

The Director's Delegate found the appellant was entirely successful and entitled to reasonable expenses.

Applying a global assessment and deducting unsubstantiated disbursements, the Delegate ordered the respondent to pay $2,250.00 for legal fees, inclusive of disbursements and HST.