Edward Lee

The applicant, a self-employed locksmith, was injured in a motor vehicle accident in 2000 and received income replacement benefits (IRBs) until the insurer terminated them in 2006.

The applicant sought post-104 week IRBs, arguing he suffered a complete inability to engage in any employment for which he was reasonably suited.

The arbitrator found the applicant credible and accepted that his chronic pain syndrome prevented him from working an eight-hour day on a full-time basis.

The insurer's experts failed to consider whether the applicant could sustain full-time hours in a structured employment setting.

The arbitrator also dismissed the insurer's request to set off alleged past overpayments against future IRBs, as the insurer had not followed the statutory notice and repayment scheme under section 47 of the Schedule.

The applicant was awarded IRBs of $185.00 per week from March 2006 onward.

Following a decision on statutory accident benefits where the insurer was found entitled to its reasonable expenses, the parties disagreed on the quantum of the insurer's Bill of Costs.

The insurer sought $6,867.08 in legal fees based on 110.7 hours of preparation and hearing time, plus disbursements.

The arbitrator found the hours excessive for a straightforward two-day hearing involving no complex legal issues.

Applying a 1.25:1 ratio for preparation to hearing time, the arbitrator reduced the legal fees and struck unsupported disbursements for courier, parking, and court reporting services.

The applicant was ordered to pay the insurer $4,861.18 in expenses.

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

The insurer denied income replacement benefits in November 2005.

The applicant applied for mediation in January 2008, beyond the two-year limitation period.

The applicant argued the initial denial was invalid because he had not yet claimed the benefits, and alternatively, that the insurer was estopped from relying on the limitation period due to its delay in responding to a later inquiry.

The arbitrator found the initial denial was valid and the insurer's conduct did not amount to estoppel.

The application was dismissed as statute-barred.

The insurer sought an order requiring the applicant's legal representative to personally pay the expenses awarded against the applicant following the dismissal of a claim for statutory accident benefits.

The representative brought a motion for summary judgment to dismiss the insurer's request.

The arbitrator found that the representative was not in a conflict of interest by participating in the motion.

The arbitrator granted the summary judgment motion, finding no evidence that the representative acted without authority, advanced a frivolous claim, or caused expenses to be wasted without reasonable cause.

The applicant was struck by a motor vehicle and claimed statutory accident benefits, including income replacement benefits (IRBs) and housekeeping benefits.

The insurer terminated IRBs and housekeeping benefits, leading to arbitration.

The arbitrator found that while the applicant's complaints of pain were likely exaggerated and lacked objective medical evidence after January 2007, he was substantially disabled from performing his pre-accident employment until his shoulder bursitis healed.

The arbitrator awarded IRBs for a closed period but dismissed the claims for ongoing IRBs, housekeeping benefits, and the cost of a redundant functional abilities evaluation.

Each party was ordered to bear their own expenses.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits from the insurer, including caregiver, housekeeping, and medical benefits.

The insurer terminated caregiver and housekeeping benefits after an occupational therapy in-home assessment.

The arbitrator found that the applicant was not substantially unable to perform her pre-accident caregiving activities, as she could still perform the essential tasks, and denied caregiver benefits.

The claim for medical benefits was denied for lack of evidence.

However, the arbitrator found the applicant was substantially unable to perform some of her pre-accident housekeeping tasks due to pain, and awarded housekeeping benefits at a reduced rate of $50 per week.

Each party was ordered to bear their own arbitration expenses.

The applicant sought to arbitrate her entitlement to Non-earner and Attendant Care benefits following a motor vehicle accident.

The insurer raised a preliminary issue that the arbitration was barred by the two-year limitation period under the Insurance Act.

The applicant argued the refusals were invalid because she lacked a full understanding of written English.

The arbitrator applied an objective test, finding the insurer provided clear and unequivocal refusals with the required dispute resolution information.

The preliminary issue was resolved in favour of the insurer, and the applicant was precluded from proceeding to arbitration.

The insurer requested an assessment of expenses following a preliminary issue hearing where expenses were awarded in its favour.

The applicant's representative withdrew from the proceeding because he was unable to contact the applicant.

The arbitrator adjourned the expense hearing and ordered the insurer to personally serve the applicant with notice of the new hearing date.

The insurer failed to personally serve the applicant, instead leaving the documents in a mailbox at her last known address without conducting further investigations.

Because the insurer failed to comply with the order for personal service by the specified deadline, the arbitrator dismissed the request for an assessment of expenses.

The applicant sought statutory accident benefits following a motor vehicle accident, including medical benefits, housekeeping expenses, and a special award.

Despite the applicant's failure to attend the hearing, his counsel proceeded.

The arbitrator dismissed the claims for medical benefits, preferring the evidence of the insurer's medical experts who conducted physical examinations over the applicant's expert who only performed a paper review.

The arbitrator also found that the treatment facility had overbilled for the duration of sessions.

The claims for housekeeping and a special award were dismissed due to lack of evidence and the finding that no benefits were unreasonably withheld.

The insurer was awarded its arbitration expenses.

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

The insurer terminated caregiver benefits, and the applicant applied for arbitration.

The insurer raised a preliminary issue that the application was filed outside the two-year limitation period under section 51(1) of the Schedule.

The applicant conceded the issue at the hearing.

The arbitrator found the applicant was precluded from proceeding and awarded $500 in expenses to the insurer.

Following a previous arbitration decision finding that the insurer unreasonably withheld payment for two treatment plans, the parties made submissions on the quantum of a special award.

Applying the criteria from Persofsky, the arbitrator determined that the insurer's imprudent and unreasonable conduct warranted a modest special award.

The arbitrator ordered the insurer to pay a special award of $3,500.00.

The applicant was injured in a motor vehicle accident and commenced a court action for accident benefits.

She later filed an Application for Arbitration at FSCO to determine catastrophic impairment and amended her court action to seek enhanced benefits.

The insurer argued the arbitration should be dismissed due to the outstanding court action.

The arbitrator held that the applicant could proceed to arbitration, provided she confirmed within thirty days that she sought leave to withdraw or discontinue her court action.

The arbitrator also permitted the applicant to add her other accident benefits claims to the arbitration.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits, including income replacement, medical, and housekeeping benefits.

The insurer terminated benefits, arguing the applicant's pain responses were exaggerated and his psychological issues stemmed from pre-existing childhood trauma rather than the accident.

The arbitrator found the applicant credible and concluded that the accident was a material contributing factor to his chronic pain syndrome, fibromyalgia, and depression.

The arbitrator awarded ongoing income replacement benefits, medical benefits for various treatments, and housekeeping benefits.

Furthermore, the arbitrator found the insurer acted unreasonably in denying certain treatment plans without a designated assessment, and ordered the insurer to pay a special award under section 282(10) of the Insurance Act.

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

The insurer terminated benefits in November 2005.

The parties disputed whether the benefits paid from March 1997 to November 2005 were Income Replacement Benefits (IRBs) or Loss of Earning Capacity Benefits (LECBs).

The arbitrator found that the benefits were IRBs, as the insurer never properly converted the IRBs to LECBs under the Statutory Accident Benefits Schedule.

The insurer's continued payment of weekly benefits after an LECB offer was rejected did not constitute an agreement to convert the benefits.

The applicant sought statutory accident benefits following a motor vehicle accident.

The applicant failed to appear at the arbitration hearing and adduced no evidence to support the claim.

The arbitrator dismissed the application and awarded $400 in expenses to the insurer.

The applicant sought statutory accident benefits following a motor vehicle accident, including medical, attendant care, and housekeeping benefits.

At the hearing, the applicant's representative withdrew as she was unable to locate or receive instructions from the applicant.

The applicant did not appear at the hearing.

As the applicant bore the burden of proof and adduced no evidence, the arbitrator dismissed the application.

The applicant was ordered to pay $400 in costs to the insurer.

The applicant was injured in a motor vehicle accident and applied for a non-earner benefit.

The insurer denied the claim and raised a limitation period defence, arguing the arbitration was commenced more than two years after a valid refusal.

The arbitrator found the refusal was invalid under the Smith v. Co-operators standard, so the arbitration was not time-barred.

The insurer was permitted to raise new defences regarding the applicant's employment and student status.

The arbitrator found the applicant was not employed or a student at the time of the accident, qualifying her to claim the non-earner benefit.

However, on the merits, the arbitrator concluded the applicant did not suffer a complete inability to carry on a normal life within 104 weeks of the accident, as she had engaged in full-time and volunteer work during that period.

The application for a non-earner benefit was dismissed.

The applicant was injured in a motor vehicle accident and sought income replacement benefits for intermittent days off work over a five-year period.

The insurer denied the claim, arguing the applicant had returned to work for more than 90 days and that an occasional disability did not constitute a substantial inability to perform essential tasks.

The arbitrator found the applicant was entitled to benefits for the days claimed, as he returned to work within 104 weeks and suffered a substantial inability on those specific days.

The arbitrator allowed the insurer to deduct sick leave benefits received.

A special award of $2,500 was ordered against the insurer for unreasonably withholding benefits despite compelling medical evidence.

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

The Insurer denied the claim on the basis that the Applicant's vehicle was uninsured at the time of the accident, as she had cancelled the policy a month prior.

The Applicant argued she had not cancelled the policy and had not received written notice of cancellation.

The Arbitrator found the Applicant's testimony unreliable and accepted the Insurer's evidence that the Applicant had initiated the cancellation.

The Arbitrator concluded that the Applicant knew or ought reasonably to have known she was operating an uninsured vehicle, triggering the exclusion under section 30(1) of the Schedule.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for various medical treatments, medications, and the cost of reports and assessments.

The insurer denied the claims based on a DAC assessment that concluded further treatment was not reasonable or necessary.

The arbitrator found that the applicant's recovery was prolonged by pre-existing conditions and psychological issues, and that the multi-disciplinary treatments provided were reasonable and necessary up to a certain date.

The arbitrator awarded partial payment for the treatments and reports, and full payment for the medications.

The claim for a special award was dismissed as the insurer's reliance on its medical reports was not unreasonable.

The applicant was awarded interest and arbitration expenses.