Fred Sampliner

The applicant was injured in a motor vehicle accident and sought arbitration after the insurer denied his claims for income replacement, attendant care, and housekeeping benefits.

The arbitrator dismissed the claim for income replacement benefits, finding the applicant's evidence regarding his self-employment as an artist and a purported employment contract to be unreliable and contradicted by his tax returns.

The claims for attendant care and housekeeping benefits were also dismissed due to a lack of supporting evidence, including the absence of a recommendation from a qualified health practitioner and no proof that outside housekeeping services were actually engaged.

All claims were dismissed.

The applicant suffered a panic attack while driving on Highway 401, causing him to exit his moving vehicle, run to the edge of the highway, and leap off the overpass onto the road below.

The insurer denied his application for statutory accident benefits, arguing the incident was not an 'accident' under the Schedule and that the panic attack was an intervening force.

The arbitrator found that the applicant's panic attack directly caused him to exit the vehicle and jump, with no break in the chain of events.

Applying the 'thin skull' principle, the arbitrator concluded the incident constituted an accident arising out of the use or operation of an automobile, entitling the applicant to claim benefits.

The applicant was injured in a motor vehicle accident and claimed statutory accident benefits, which the insurer denied.

The applicant subsequently died, and her estate failed to appear at the arbitration hearing.

As the estate failed to meet its burden of proof, its claims for caregiver benefits, housekeeping expenses, a special award, and arbitration expenses were dismissed.

The insurer's claims for repayment of benefits and arbitration expenses were also dismissed because it presented no evidence or submissions.

The applicant was injured in a motor vehicle accident and claimed housekeeping expenses under the Statutory Accident Benefits Schedule.

The insurer denied the benefits based on an in-home assessment.

The arbitrator found the applicant suffered a substantial inability to perform his pre-accident housekeeping activities for a limited period and awarded $315 in housekeeping benefits.

The arbitrator also granted a $40 special award because the insurer unreasonably withheld benefits for a four-week period prior to the assessment.

The insurer's claim that the arbitration was frivolous or vexatious was dismissed.

Following the dismissal of the applicant's claims for statutory accident benefits, the insurer sought an assessment of its arbitration expenses.

The arbitrator reviewed the insurer's docketed time and reduced the hours claimed, finding that the issues were straightforward and the hearing was brief.

The arbitrator awarded the insurer $2,244.93 in fees and disbursements but declined to award the $3,000 arbitration assessment fee, as the insurer had not provided prior notice of a claim that the proceeding was frivolous, vexatious, or an abuse of process.

The insurer requested a preliminary issue hearing to determine whether the insured was precluded from proceeding to arbitration due to her refusal to attend a psychiatric examination scheduled by the insurer.

The arbitrator found that the insurer had ample notice of the insured's psychological symptoms but waited until after the pre-hearing to schedule the examination.

The arbitrator concluded the request was a tactical maneuver to bolster the insurer's case rather than for adjusting purposes.

The insurer's request was deemed unreasonable, and the insured was permitted to proceed to the arbitration hearing.

Following a decision denying the applicant's claim for income replacement benefits, the insurer sought an award of its arbitration expenses, alleging the applicant caused delays and called unnecessary witnesses.

The arbitrator found no evidence of intentional obstruction or neglect by the applicant, noting the insurer raised its successful exclusion defence only a month before the hearing.

The arbitrator concluded that the applicant acted in good faith and ordered each party to bear its own costs.

The applicant sustained a serious traumatic brain injury in a motor vehicle accident and received medical and rehabilitation benefits for ten years.

The insurer denied further benefits after the ten-year anniversary pursuant to subsection 6(3) of the Statutory Accident Benefits Schedule.

The applicant argued that her ongoing treatments should be covered under the exception for single treatments delivered in stages.

The arbitrator dismissed the claims, finding that the ongoing expenses for items such as pedicures, chiropractic care, and assistive devices were continuous series of treatments rather than a single service bridging the limitation period.

The applicant was injured in a motor vehicle accident and sought ongoing income replacement benefits and payment for treatment expenses after the insurer terminated them.

The applicant failed to attend the arbitration hearing.

The arbitrator reviewed the insurer's evidence, including medical opinions indicating the applicant was capable of returning to work as a manicurist.

The arbitrator found the applicant failed to meet the burden of proving a substantial inability to perform the essential tasks of his employment or that the disputed treatment was reasonable and necessary.

The claims were dismissed, and the insurer was awarded its expenses for the arbitration.

The applicant was injured in two separate automobile accidents.

She claimed income replacement benefits from the first accident and caregiver benefits from the second.

The insurer argued that under section 36(1) of the Statutory Accident Benefits Schedule, she could not receive both benefits concurrently, and sought to deduct an alleged overpayment from the first accident against the caregiver benefits.

The arbitrator held that section 36(1) applies only to benefits claimed from a single accident and does not bar receiving different benefits from separate accidents.

Furthermore, the insurer could not deduct past overpayments from current entitlements arising from a different accident under section 47(1).

The preliminary issues were resolved in favour of the applicant.

The applicant sought statutory accident benefits after being struck by a bicycle while walking away from his friend's parked van, having just retrieved a package from it.

The insurer denied the claim on the basis that the incident did not meet the definition of an 'accident' under the Statutory Accident Benefits Schedule.

The arbitrator held that while retrieving a package is an ordinary activity attached to automobile use, the direct cause of the injuries was the bicycle, which constituted a new and independent intervening force.

The applicant's proximity to the vehicle was merely coincidental.

The claim for accident benefits was dismissed.

The applicant was injured in a rear-end motor vehicle accident and received income replacement benefits until they were terminated by the insurer.

The applicant applied for arbitration, claiming ongoing neck and back pain, headaches, and sleep loss prevented him from returning to his job as a machine operator.

The arbitrator found the applicant's evidence unreliable due to a lack of candour regarding pre-existing conditions.

Relying on functional abilities evaluations and medical evidence characterizing the injuries as mild to moderate, the arbitrator concluded the applicant failed to establish a substantial inability to perform the essential tasks of his pre-accident employment.

The claim for ongoing income replacement benefits was dismissed.

The insurer brought a motion to stay the insured's arbitration proceeding at the Financial Services Commission of Ontario (FSCO) pending the outcome of a lawsuit it had filed in the Superior Court of Justice.

The insurer argued that its lawsuit, which sought a determination of the insured's income replacement benefit and repayment of alleged overpayments, was filed two days before the arbitration application.

The arbitrator dismissed the motion, finding that the arbitration had advanced more rapidly than the lawsuit and that a stay would frustrate the goal of avoiding multiple proceedings, as the court lacked jurisdiction to issue a special award.

The arbitrator emphasized that the Insurance Act gives the insured, not the insurer, the right to elect the forum for dispute resolution.

The applicant was injured in a motor vehicle accident while driving with a G1 novice licence without an accompanying fully licenced driver, in violation of his licence conditions.

He applied for income replacement benefits.

The insurer denied the claim under s. 30(1)(b) of the Statutory Accident Benefits Schedule, arguing he was driving without a valid driver's licence.

The arbitrator held that breaching the novice licence restriction constituted driving without a valid licence within the meaning of the exclusion.

The arbitrator also found that the insurer did not waive its right to assert the exclusion despite initially paying benefits, as there was no intentional relinquishment of the right.

The arbitration was dismissed.

The applicant sought payment of the balance of an arbitration award and his expenses for the arbitration.

The insurer claimed an overpayment of interest as a setoff, arguing the pre-hearing arbitrator had suspended interest.

The arbitrator found he had jurisdiction to decide the interest issue and declined to suspend interest, ordering the insurer to pay the $302.92 balance.

The arbitrator also assessed the applicant's arbitration expenses, allowing legal fees, agent fees at a law clerk rate, and disbursements, awarding a total of $5,033.66 in expenses.

The insurer sought its arbitration expenses and assessment fee after the applicant's claim for statutory accident benefits was dismissed on the basis that no motor vehicle accident occurred.

The arbitrator found that the applicant falsely represented that an accident occurred and knowingly pursued a fraudulent claim, constituting an abuse of process.

The arbitrator awarded the insurer $3,388.50 in arbitration expenses and the $3,000 assessment fee.

The applicant, a plumber, was injured in a motor vehicle accident and sought income replacement benefits (IRBs) after the insurer terminated them.

The arbitrator found that the accident aggravated the applicant's pre-existing back condition, causing a substantial inability to perform the essential tasks of his job, particularly driving long distances and working in awkward positions.

The applicant was awarded IRBs for the disputed period, along with interest.

Claims for medical assessment expenses and an MRI were dismissed as they were either arbitration expenses or not properly claimed under the Schedule.

The claim for a special award was also dismissed, as the insurer had a justifiable basis for terminating benefits based on a DAC report.

The applicant sustained a permanent knee injury in a motor vehicle accident and sought ongoing income replacement benefits and funding for university retraining as an engineer.

The insurer terminated benefits based on a vocational assessment identifying alternative employment.

The arbitrator found the insurer's job recommendations unsuitable due to the applicant's physical limitations and pre-accident earnings, and drew an adverse inference against the insurer for failing to arrange a required Designated Assessment Centre evaluation.

The applicant was awarded ongoing income replacement benefits, but his claim for engineering retraining was dismissed as it was not similar to his pre-accident employment as a roofing supervisor.

The applicant was partially successful in her claim for statutory accident benefits, recovering less than the insurer's pre-hearing settlement offer.

The insurer argued it should be awarded its expenses because its offer exceeded the recovery.

The arbitrator rejected a strict results-based approach but noted the applicant had sufficient guidance from prior decisions to evaluate the offer.

The arbitrator exercised discretion to award the applicant half of her arbitration expenses, totaling $1,500.

The applicant was injured in a motor vehicle accident and sought income replacement benefits and treatment expenses from the insurer.

The insurer had terminated benefits a few months after the accident, arguing the applicant's ongoing symptoms were due to pre-existing conditions.

The arbitrator found the applicant to be an unreliable historian regarding his pre-accident health, relying instead on the clinical notes of his family physician which documented extensive pre-existing chronic pain and depression.

However, the arbitrator accepted that the accident exacerbated the applicant's neck pain and anxiety, causing a substantial inability to perform his pre-accident job as a snowplow operator for a limited period.

The applicant was awarded income replacement benefits until December 1, 1994, but his claim for ongoing benefits and treatment expenses was dismissed.