Fred Sampliner

The applicant was injured in a rear-end motor vehicle accident and sought reimbursement for acupuncture treatments, treatment plans, reports, and transportation expenses under the Statutory Accident Benefits Schedule.

The insurer denied the claims, arguing the symptoms were pre-existing.

The arbitrator found that the accident significantly contributed to the applicant's neck and shoulder pain, but not her knee, left arm, or low back complaints.

The applicant was awarded partial reimbursement for the acupuncture treatments and reports related to the accident injuries.

Claims for treatment plans were denied because the acupuncturist was not a member of a regulated health profession.

Transportation expenses were denied as the applicant failed to prove she could not walk or use a family vehicle.

Neither party was awarded arbitration expenses due to the inefficient conduct of the hearing.

The insurer requested a correction to a previous arbitration order regarding the calculation of Loss of Earning Capacity (LEC) benefits.

The arbitrator found jurisdiction under the Statutory Powers and Procedure Act and the Dispute Resolution Practice Code to correct the technical calculation error, which had failed to deduct UI, CPP, and income tax from the pre-accident income.

The LEC benefits were recalculated and reduced accordingly.

The arbitrator also determined that the insured was entitled to her expenses of the arbitration process, as she was largely successful in establishing her entitlement to the LEC benefit and the insurer had not made an offer to settle.

The applicant was injured in a motor vehicle accident and received income replacement benefits from her automobile insurer, Coseco, as well as long-term disability benefits from London Life through her employer.

Coseco deducted the London Life benefits from the income replacement benefits.

The applicant disputed this deduction, arguing the matter was not settled at mediation and the deduction was unfair.

The arbitrator found that the London Life policy qualified as an income continuation plan under section 7(1) of the Statutory Accident Benefits Schedule, as it provided income security for loss of wages and was tied to her earnings.

Therefore, Coseco was entitled to deduct the collateral benefits.

Each party was ordered to bear their own costs.

The applicant sought statutory accident benefits following an alleged motor vehicle accident.

The insurer terminated benefits and sought repayment, alleging the applicant was not in the vehicle and had misrepresented his employment.

The applicant did not attend the arbitration hearing.

The arbitrator found, based on police and witness evidence, that the applicant was not in the vehicle and had submitted false employment information.

The applicant's claims were dismissed.

The insurer was awarded repayment of benefits paid, its arbitration assessment fee, and its expenses of the arbitration.

The applicant sought accident benefits following an alleged motor vehicle accident on December 31, 2000.

The insurer denied the claim, arguing the accident did not occur.

At the arbitration hearing, the insurer presented expert evidence from an accident investigator who testified that the physical damage to the vehicles was inconsistent with the reported collision and matched pre-existing damage from 1997.

The arbitrator accepted the expert's unrebutted evidence, found that the applicant was not involved in the alleged accident, and dismissed the claim for accident benefits.

The applicant was injured in a motor vehicle accident and claimed statutory accident benefits, including a loss of earning capacity (LEC) benefit, housekeeping expenses, and shop assistant expenses.

The arbitrator determined the applicant's pre-accident earning capacity based on her reported income and unreported tips, and found she had no residual earning capacity due to a mild to moderate brain injury.

The claim for a shop assistant was dismissed as an unreasonable rehabilitation expense, while the claim for housekeeping expenses was allowed.

The applicant's request for a special award was dismissed.

The insurer moved to stay the applicant's arbitration hearing on the basis that she refused to attend the insurer's health care and vocational examinations.

The examinations were scheduled shortly before the hearing, and the resulting reports would not have been served within the 30-day disclosure period required by the Dispute Resolution Practice Code.

The arbitrator found that the late delivery of the reports would prejudice the applicant's ability to prepare for the hearing.

The insurer's request for the examinations was deemed unreasonable, and the motion to stay the arbitration was dismissed.

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

She later signed a full and final release.

Over a year later, she underwent five health care assessments and sought reimbursement from the insurer.

The insurer denied the claims, initially relying on the release but later withdrawing that defence.

The arbitrator found that the applicant had recovered from her accident injuries at the time of the assessments and that her ongoing issues were due to pre-existing work-related hand injuries.

The assessments were deemed not reasonable expenses for the purpose of the Regulation.

The claim for a special award was also dismissed, as the insurer acted reasonably in relying on the release before the law changed.

The applicant failed to appear at a scheduled preliminary issue hearing regarding his entitlement to statutory accident benefits.

His representative had faxed a late adjournment request citing a scheduling conflict but provided no substantiating details and unilaterally declared they would not attend.

The arbitrator found the late adjournment request unjustified and an abuse of process.

However, rather than deciding the preliminary issue in the applicant's absence, the arbitrator deferred it to be heard with the main arbitration, on the condition that the applicant pay the insurer $335 in wasted costs for the day.

Following a decision on statutory accident benefits where the applicant achieved minimal success, the parties sought their respective expenses of the arbitration proceeding.

The arbitrator rejected the insurer's proposal to apportion costs 75/25 in its favour, noting that the applicant was justified in proceeding to arbitration given the insurer's low settlement offer.

However, due to the applicant's minimal success, he was awarded only 20% of his arbitration expenses.

The insurer's claim for expenses was dismissed.

The applicant's counsel's hourly rate was set at $73.38 based on the legal aid tariff.

The insurer brought a motion to vary an arbitration order that had directed it to pay for three medical reports as section 24 expenses under the Statutory Accident Benefits Schedule.

The applicant did not appear.

The arbitrator found that the applicant had not formally applied for these expenses under section 24 and that the reports were commissioned primarily to establish his claims in the arbitration process.

The arbitrator varied the order, recharacterizing the medical reports as expenses of the arbitration process rather than section 24 benefits.

The applicant was injured in a motor vehicle accident and subsequently developed severe psychological problems, including delusions and paranoia.

He applied for income replacement benefits, which the insurer denied on the basis that his psychological condition was pre-existing and not caused by the accident.

The arbitrator found that the applicant was a 'thin-skulled' individual whose vulnerable defences were overwhelmed by the accident, establishing causation.

The applicant was awarded ongoing income replacement benefits, but his claim for a special award was dismissed as the insurer had not unreasonably delayed or withheld benefits.

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

The insurer terminated benefits, and the applicant sought ongoing income replacement, attendant care, and housekeeping benefits.

The arbitrator found that the applicant did not suffer a complete inability to engage in suitable employment due to physical injuries, but did suffer such an inability due to psychological complications (severe depression and anxiety) until her condition stabilized.

The arbitrator awarded income replacement benefits for a closed period.

The claims for attendant care and housekeeping expenses were dismissed because the applicant failed to prove she incurred a cost or obligation to pay her husband for those services.

In a supplementary arbitration decision, the applicant sought reimbursement for medical and rehabilitation expenses initially funded by the Workers' Compensation Board (WCB) following a motor vehicle accident.

The insurer had reimbursed most of the amount but withheld $2,901.54, arguing it was covered by OHIP.

The arbitrator found no settlement had been reached between the parties and ordered the insurer to pay the remaining $2,901.54, as it failed to provide sufficient evidence of OHIP coverage.

The arbitrator also awarded interest on the overdue amounts from October 1, 1998, and set the applicant's counsel fee rate at $125 per hour for the arbitration proceeding.

The applicant sought death and funeral benefits after her son was shot and killed in an underground parking garage while performing maintenance on his vehicle.

The insurer denied the claim on the basis that the death was not an 'accident' under the Statutory Accident Benefits Schedule.

The arbitrator dismissed the application, finding that the vehicle did not play a direct instrumental role in the chain of events leading to the death.

The direct and intervening cause of death was the gunshot, not the normal use and operation of the automobile.

The insurer applied to vary or revoke a previous arbitration decision ordering it to pay for the insured's physiotherapy treatment and interest.

The insurer argued the insured was barred from receiving benefits under s. 43(3) of the Statutory Accident Benefits Schedule because he failed to attend a Designated Assessment Centre (DAC) examination.

The arbitrator found that while the insured did fail to make himself reasonably available, this failure occurred after the physiotherapy treatment had already concluded.

Therefore, the exclusion did not apply retroactively to the completed treatment.

The arbitrator also held that the insured was entitled to interest on the overdue benefits, as the Schedule does not provide for the forfeiture of interest due to non-compliance.

The insurer's application was dismissed and interest was ordered.

The applicant was involved in two motor vehicle accidents and sought arbitration for further physiotherapy treatment.

The insurer sought to include a repayment claim for $3,260 it had previously paid for physiotherapy, arguing the treatment was unreasonable.

The applicant objected, arguing the tribunal lacked jurisdiction to hear insurer repayment claims and that such claims should be heard in court.

The arbitrator held that under the Insurance Act, arbitrators have jurisdiction to determine all issues in dispute, including insurer repayment claims that arise out of the same issues raised by the insured.

The repayment claim was ordered to be included in the arbitration proceeding.

The applicant sought statutory accident benefits, including non-earner disability benefits and income replacement benefits, following a motor vehicle accident.

The applicant failed to attend the arbitration hearing and his subsequent request for an adjournment was denied.

The arbitrator dismissed the claims for benefits, finding that the applicant's medical evidence was unsupported by diagnostic imaging and contradicted by surveillance video showing him working and moving freely.

Claims for interest and arbitration expenses by both parties were also dismissed.

The applicant was injured in a motor vehicle accident and received weekly disability benefits until May 1997.

He applied for ongoing disability benefits and reimbursement for three medical reports.

The arbitrator found that the applicant failed to establish a substantial inability to perform the essential tasks of his pre-accident job as a video salesman, as his medical experts did not address his actual job duties.

The claim for ongoing weekly benefits was dismissed.

However, the arbitrator ordered the insurer to reimburse the applicant for the costs of the three medical reports, finding they were reasonably incurred under section 24 of the Statutory Accident Benefits Schedule to establish entitlement to benefits.

The applicant sought payment for various medical and rehabilitation expenses following a motor vehicle accident.

The insurer denied the claims, arguing in part that the referring physician had an undisclosed conflict of interest regarding one of the treatment centres.

The arbitrator found that while the physician failed to disclose his ownership of the centre, the insurer had not previously approved the treatment plan, meaning the automatic exclusion under section 38(20) of the Schedule did not apply.

However, the arbitrator scrutinized the medical necessity of the treatments, awarding partial costs for acupuncture, the family physician's accident-related services, and certain diagnostic testing, while denying costs for structured physiotherapy.

The arbitrator also awarded overdue interest and dismissed the insurer's claim for repayment of disability benefits due to lack of proper notice.