K. Julaine Palmer

The insurer brought a motion to stay the arbitration hearing until the applicant attended two insurer's examinations (orthopaedic and psychological/neuropsychological) and to compel the production of raw test data from the applicant's psychologist.

The arbitrator dismissed the request for the examinations, finding the insurer failed to prove they were reasonably necessary, as the applicant had not been treated by an orthopaedic surgeon and was not claiming a brain injury.

However, the arbitrator ordered the production of the raw test data to a psychologist retained by the insurer or directly to the insurer's counsel.

The applicant sought a special award under s. 282(10) of the Insurance Act, alleging the insurer unreasonably delayed paying income replacement benefits and setting up a direct payment account for prescription medication following a settlement agreement.

The arbitrator found no unreasonable delay regarding the income replacement benefits, as the applicant had been overpaid.

The arbitrator found the insurer unreasonably delayed setting up the medication account, but dismissed the claim for a special award because the applicant failed to provide any evidence of the cost of the medications, which is required to calculate the award.

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

The applicant failed to attend the arbitration hearing, and his counsel was granted leave to withdraw.

Relying on the insurer's medical evidence that the applicant's ongoing impairment was related to a prior workplace accident, the arbitrator dismissed the claim for benefits.

The arbitrator found the applicant's failure to attend or maintain contact with his counsel constituted an abuse of process, ordering him to pay $3,000 under subsection 282(11.2) and $1,000 in expenses under subsection 282(11) of the Insurance Act.

The applicant was injured in a motor vehicle accident and sought payment for chiropractic and rehabilitation treatments from his automobile insurer.

The insurer disputed the necessity and cost of the treatments, and argued that the applicant's extended health insurer was the primary payer.

The arbitrator held that the legal burden of proof lies with the insured to demonstrate what collateral benefits were reasonably available and what balance remains owing by the automobile insurer.

The arbitrator found the treatments were reasonable and necessary, adjusted the allowable costs, and ordered the insurer to pay the outstanding balance of $993.

A special award of $250 was also granted against the insurer for unreasonably delaying payment.

The applicant applied for arbitration regarding her entitlement to loss of earning capacity benefits following a motor vehicle accident.

The insurer raised a preliminary issue, arguing the applicant was precluded from proceeding to arbitration because she refused to attend an updated insurer's medical examination.

The arbitrator found the insurer's request for a single updated examination by a doctor who had previously examined the applicant was reasonable and not overly onerous.

The applicant was ordered to attend the examination before proceeding to arbitration.

The applicant claimed statutory accident benefits from the transit insurer following a bus accident.

The insurer denied the claim, arguing the applicant was covered under her estranged husband's policy with another insurer and had wilfully misrepresented her coverage status on her application.

The arbitrator found that the applicant, through her legal representative, intentionally or recklessly failed to disclose her spouse's insurance policy on her application.

As a result, the applicant was precluded from receiving benefits from the transit insurer due to wilful misrepresentation under subsection 48(1) of the Statutory Accident Benefits Schedule.

The application was dismissed with no costs awarded.

The applicant applied for statutory accident benefits, claiming she was injured as a passenger in a motor vehicle accident.

The insurer denied the claim on the basis that the applicant was not in the vehicle at the time of the collision.

In a preliminary issue hearing, the arbitrator assessed the credibility of the applicant, her sister, and the driver.

Despite some inconsistencies regarding the time of the accident and weekend plans, the arbitrator found on a balance of probabilities that the applicant was a passenger in the vehicle and suffered an impairment, thereby meeting the definition of an accident.

The applicant, a self-employed electrician, sought weekly income replacement benefits following a motor vehicle accident in October 1994.

The arbitrator dismissed the application, finding that the applicant failed to provide sufficient medical or documentary evidence to prove he suffered a substantial inability to perform the essential tasks of his employment.

Furthermore, the applicant failed to provide adequate financial documentation to substantiate his claim for loss of income and the costs of replacement workers.

The issues of medical report costs and arbitration expenses were deferred.

Following a decision awarding the applicant statutory accident benefits for home renovations, the parties disputed the date from which interest should run.

The arbitrator found that the insurer's letter of December 9, 1999, clarifying its position on the renovation costs, constituted a refusal to pay under s. 24(8) of the Schedule.

The insurers were ordered to pay interest at two percent per month on the outstanding balance of $32,041 plus GST from December 9, 1999, until the obligations under the previous order were discharged.

The applicant, a pedestrian injured in a motor vehicle accident, applied for income replacement benefits and non-earner benefits.

He claimed he had two future contracts of employment made before the accident.

The arbitrator found the applicant's evidence regarding the employment contracts to be fabricated, illogical, and inconsistent, concluding he did not meet the eligibility criteria for income replacement benefits.

The claim for non-earner benefits was also dismissed as the medical evidence and the applicant's continued university attendance did not support a complete inability to carry on a normal life.

The applicant was ordered to pay the insurer's arbitration expenses due to his conduct and fabrication of evidence.

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

The insurer terminated the benefits based on a Designated Assessment Centre (DAC) report concluding the applicant did not suffer a complete inability to engage in any employment for which he was reasonably suited.

The applicant disputed the termination, relying on a failed work trial and expert medical opinions indicating he could not sustain employment due to chronic pain.

The arbitrator rejected the DAC's conclusion, finding its process flawed and its functional abilities testing inadequate to measure the applicant's actual ability to work.

The arbitrator held that the applicant met the test for complete inability to engage in suitable employment and ordered the insurer to pay ongoing income replacement benefits and the expenses of the arbitration.

The applicant was injured in a motor vehicle accident and sought income replacement benefits (IRBs) and rehabilitation benefits from her insurer.

She continued to work as a process server for several months post-accident before stopping due to chronic pain.

The arbitrator found that the applicant suffered a substantial inability to perform the essential tasks of her employment and awarded IRBs for 103 weeks, plus an additional 9 weeks during a crisis period when she was completely unable to engage in any employment.

The arbitrator also awarded rehabilitation benefits for a driver education instructor course, finding it was a reasonable and necessary measure to reintegrate her into the labour market.

The insurer's failure to promptly advise the applicant that a treatment plan was required precluded it from relying on her failure to submit one.

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

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

The insurer denied certain treatment plans and requested the applicant attend insurer's examinations and a Designated Assessment Centre (DAC).

The applicant failed to return the required OCF-14/59 forms for the DAC and did not attend the insurer's examinations.

On a preliminary issue, the arbitrator held that the insurer's notice for the examinations was defective for failing to specify the benefits to which they related, meaning the applicant was not barred from arbitrating other issues.

However, the applicant's failure to return the DAC forms constituted a failure to make himself reasonably available for an assessment, barring him from arbitrating the specific treatment plans related to those DACs.

The applicant filed for arbitration over a $650 claim but later sought to withdraw on a without-costs basis after his engagement broke off and his former fiancée no longer wished to pursue the matter.

The insurer refused to consent to the withdrawal unless the applicant repaid the $3,000 assessment fee the insurer was required to pay to the Commission, arguing the arbitration was frivolous, vexatious, and an abuse of process.

The arbitrator found that the application was not frivolous or vexatious, noting that applicants with small claims must have the opportunity to pursue arbitration.

The arbitrator ordered that each party bear its own expenses, concluding that both parties could have avoided costs with more sincere informal attempts to settle.

The applicant sought her expenses following an arbitration decision regarding statutory accident benefits.

The arbitrator found that success was divided, as the applicant was unsuccessful in her claim for ongoing income replacement benefits and a special award, but successful in correcting the amount of her income replacement benefit and resisting the insurer's claim for repayment based on alleged fraud.

The arbitrator awarded the applicant one-half of her assessed expenses, calculated at Legal Aid rates rather than the requested maximum rate, resulting in an award of $11,414.28.

The applicant was injured in a motor vehicle accident and received income replacement benefits until the insurer terminated them, relying on an ergonomist's report.

The applicant applied for arbitration, arguing he remained substantially unable to perform the essential tasks of his pre-accident job as a machine operator due to a shoulder injury and a traumatic brain injury.

The arbitrator found the ergonomist's report fundamentally flawed and accepted the evidence of the applicant's experts and an orthopaedic specialist retained by the insurer.

The arbitrator concluded the applicant was entitled to ongoing income replacement benefits, subject to deductions for post-accident earnings, and ordered a 15% special award against the insurer for unreasonably withholding benefits.

The applicant, who was left with partial quadriplegia following two motor vehicle accidents, sought statutory accident benefits for the purchase and renovation of a new home to accommodate his needs.

The insurers had advanced $135,000 based on the estimated cost of renovating his previous townhouse, arguing they were not responsible for the capital cost of a new home.

The arbitrator found that while the applicant reasonably required extensive home modifications, including an additional bedroom, an accessible bathroom, and an elevator, the insurers were not obligated to fund the purchase price of the freehold home itself.

The arbitrator ordered the insurers to pay $153,410 for renovations and the capital cost of an additional bedroom, plus a project management fee, but dismissed the claim for a special award, finding the insurers had not unreasonably withheld payments.

The applicant was injured in a motor vehicle accident and sought payment of $800 for an in-home assessment conducted by a kinesiologist.

The insurer denied the expense, arguing it was not reasonable or necessary and did not meet the criteria of section 24 of the Statutory Accident Benefits Schedule.

The arbitrator found that the applicant failed to prove the assessment was obtained "for the purpose of the Regulation," as there was no evidence connecting the referral to the accident or showing the report was used for rehabilitation or benefit entitlement.

The application for payment was dismissed.

The applicant sustained a severe brain injury in a motor vehicle accident and required long-term care in a nursing home.

She sought payment from her insurer for chronic care co-payments, ongoing and retroactive attendant care, rehabilitation services, and a special award.

The arbitrator held that the insurer was primarily responsible for paying the long-term care accommodation fees under the Statutory Accident Benefits Schedule, subject to deductions for the applicant's low-income subsidy.

The arbitrator awarded ongoing and retroactive funding for a community support worker to reduce the applicant's social isolation, as well as funding for a case manager and specific therapy assessments.

A special award of $10,000 was ordered against the insurer for unreasonably withholding the co-payments and misrepresenting its obligations under the Schedule.

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

The insurer conceded entitlement but disputed the quantum of legal fees and expert disbursements.

The arbitrator assessed the legal fees, allowing the full time claimed by the junior lawyer who had carriage of the file, but reducing the time claimed by the senior lawyer for duplication.

The arbitrator also assessed the disbursements for various medical experts, reducing some hourly rates to the maximum allowed under Schedule F of the Dispute Resolution Practice Code, and reducing the amounts claimed for certain medical assessments and reports.

The total expenses awarded were $18,888.71.