Nancy Makepeace

The appellant, a taxicab driver, was assaulted and struck on the head with a rock by a passenger during an attempted robbery.

He applied for statutory accident benefits, which were denied on the basis that the incident was not an 'accident' under section 2(1) of the SABS-1996.

The Arbitrator found that the vehicle was merely the location of the assault and did not directly cause the impairment.

On appeal, the Director's Delegate upheld the Arbitrator's decision, concluding that the assault, not the use or operation of the automobile, was the direct cause of the impairment.

The appeal was dismissed, but the respondent was ordered to pay the appellant's appeal expenses.

The appellant, a truck driver, was ambushed, beaten, and shot after stopping to ask for directions.

He claimed statutory accident benefits, arguing the incident was an 'accident' under the SABS-1996.

The Arbitrator found that the use or operation of the truck did not directly cause his injuries.

On appeal, the Director's Delegate upheld the decision, finding that the assault was an intervening act and the truck was merely the location of the attack, not the direct cause of the impairment.

The insurer appealed an arbitrator's decision that the criminal offences exclusion in subsections 30(4) and (5) of the SABS-1996 did not apply to income replacement benefits payable after the insured's conviction for assault.

The Director's Delegate allowed the appeal, finding that the exclusion applies to benefits that would otherwise be payable both before and after a conviction.

The arbitrator's interpretation would produce absurd consequences and violate public policy by allowing a convicted person to receive benefits after being found guilty.

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

The insurer terminated weekly income benefits after 156 weeks.

The applicant sought ongoing benefits, claiming she was continuously prevented from working as a dressmaker due to chronic pain and fibromyalgia.

The arbitrator dismissed the claim for ongoing benefits, relying heavily on surveillance evidence that contradicted the applicant's reported functional limitations.

However, the arbitrator found that collateral benefits received by the applicant from private disability policies were not deductible from her pre-156 week income benefits, ordering the insurer to pay the shortfall with interest.

The insured suffered catastrophic injuries in a motor vehicle accident and was placed in a long-term care facility.

A dispute arose over whether her automobile insurer was required to pay her chronic care accommodation co-payments under the SABS-1994.

The arbitrator ordered the insurer to pay the full co-payments and awarded a $10,000 special award.

On appeal, the Director's Delegate varied the order, finding that while the insurer is responsible for the co-payments, the SABS secondary payer rule requires the insured to apply for reasonably available partial or full exemptions under the Health Insurance Act to reduce the amount payable.

The special award was revoked because the insurer's delay was not unreasonable given the insured's failure to pursue these exemptions.

The Delegate also revoked the arbitrator's award for past attendant care and support worker services that were never actually incurred.

The appellant abandoned his appeal before the Financial Services Commission of Ontario after his representative was excluded from the proceeding for obstructive conduct during a bias motion.

The Director's Delegate dismissed the appeal and confirmed the arbitrator's order.

The appellant was ordered to pay the respondent's appeal expenses of $1,507.50 due to the frivolous and vexatious nature of the bias motion and the representative's conduct.

The appellant, who suffered a severe brain injury after being struck by an automobile, appealed an arbitrator's decision limiting her attendant care benefits to the minimum hourly wage for Level II care under the SABS-1994.

The insurer cross-appealed the finding that the appellant qualified for education disability benefits despite having withdrawn from high school prior to the accident.

The Director's Delegate dismissed both the appeal and cross-appeal, finding that the regulation strictly limited Level II attendant care to the minimum wage, and that the appellant's withdrawal from school less than a year before the accident satisfied the criteria for having 'completed her education' under the schedule.

The appellant appealed an arbitration decision regarding statutory accident benefits.

During the appeal, the appellant's non-lawyer agent brought a motion alleging institutional bias against the Financial Services Commission of Ontario.

The agent repeatedly failed to comply with procedural orders, made incoherent submissions, and demonstrated open contempt for the tribunal.

The Director's Delegate ordered the agent excluded from the proceeding pursuant to section 23(3) of the Statutory Powers Procedure Act, finding him incompetent to properly represent the appellant and failing to comply with the duties of an advocate.

The appellant appealed an arbitration order finding her claims for various statutory accident benefits were statute-barred.

The central issue was whether the insurer's notice terminating her weekly income benefits was clear and unequivocal enough to trigger the two-year limitation period under the Insurance Act.

The Director's Delegate held that while the arbitrator erred in considering the parties' prior and subsequent conduct to assess the clarity of the notice, the notice itself was substantially clear and unequivocal despite containing technical errors.

The appeal was dismissed and the arbitration order confirmed.

Allstate appealed an arbitration order awarding the respondent $3,655.41 for rehabilitation expenses at a clinic.

Allstate argued the arbitrator erred in law by classifying the kinesiology treatment as 'one-to-one' and allowing an $80 hourly rate, and by finding the clinic's assessment fees were not recoverable from OHIP.

The Director's Delegate dismissed the appeal, finding no error of law in the arbitrator's conclusion that the $80 hourly fee was a reasonable and necessary expense given the respondent's age and complex medical history.

The Delegate also upheld the finding that the specific assessment fees were payable by the insurer, as the arbitrator was entitled to accept evidence that the clinic could not bill OHIP for them.

The appellant was injured in a motor vehicle accident and sought payment for a multidisciplinary assessment under s. 24 of the SABS-1996.

The arbitrator allowed the costs for the physiotherapy and functional abilities assessments but denied the cost of the orthopaedic assessment.

Both parties appealed.

The Director's Delegate dismissed the appeal and cross-appeal, finding that the arbitrator correctly applied a flexible, contemporaneous reasonableness test to determine whether the assessments were obtained for the purpose of the regulation.

The Delegate also declined to admit fresh evidence on appeal and dismissed a motion alleging institutional bias.

The appellant appealed an arbitration decision that terminated her weekly income benefits and ordered her to repay a portion of her psychological treatment costs.

On a preliminary motion, the appellant sought an order requiring the insurer to provide full transcripts of the arbitration hearing and to admit fresh evidence.

The Director's Delegate ordered the insurer to arrange and pay for the transcription of the untranscribed portions of the treating psychologist's testimony, finding it necessary for a fair hearing of the appeal.

The motion to admit fresh evidence was dismissed, except for a Canada Pension Plan Review Tribunal decision, which was admitted.

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

The insurer made an offer of Loss of Earning Capacity Benefits (LECBs).

The applicant disputed the residual earning capacity (REC) component but did not expressly dispute the pre-accident earning capacity (PEC) component within 45 days.

The insurer brought a preliminary motion arguing the applicant was time-barred from arbitrating the PEC issue under s. 281(5) of the Insurance Act and s. 72(1) of the Schedule.

The arbitrator dismissed the motion, finding that under the Schedule, silence is deemed a rejection of both the REC and PEC components of the offer, and the limitation period had not expired.

The applicant was injured in a serious motor vehicle accident and received income replacement benefits (IRBs).

The insurer terminated IRBs after the applicant attempted a return to work but had to stop due to severe headaches and vomiting.

The insurer later reinstated benefits and paid arrears on the eve of the arbitration hearing.

The arbitrator found that the insurer unreasonably withheld benefits by ignoring the overwhelming medical evidence from treating practitioners and selectively reading its own experts' reports.

The arbitrator awarded a special award of $25,000, inclusive of compound interest, under s. 282(10) of the Insurance Act.

Allstate sought to appeal an arbitrator's preliminary decision that collateral benefits were not available to the respondent, Mr. Torok, because his application to the collateral insurer was out of time.

The Director's Delegate rejected the appeal pursuant to Rule 46.2 of the Dispute Resolution Practice Code, which generally prohibits appeals of preliminary orders until all issues are finally decided.

The Delegate found that the appeal was not compelling on its face, involved factual disputes, and would likely delay the scheduled entitlement hearing, causing prejudice to the respondent.

Following an arbitration and appeal regarding statutory accident benefits, the applicant sought an assessment of his arbitration expenses.

The insurers argued that the appeal automatically stayed the arbitration expenses order, but the arbitrator noted that under the Insurance Act, an appeal does not stay an order unless the Director decides otherwise.

The arbitrator assessed the applicant's claimed legal fees and disbursements, allowing a portion of the preparation time and expert witness fees.

After accounting for set-offs for collateral benefits and the insurers' appeal expenses, Allstate was ordered to pay $3,569.45 and Wellington was ordered to pay $6,381.95.

The applicant was injured in a minor motor vehicle accident and claimed income replacement benefits, alleging he was unable to work as a truck driver due to headaches and concentration problems.

The insurer denied the benefits based on insurer medical examinations.

The arbitrator found the applicant's evidence of disability to be sparse, contradictory, and unsupported by medical evidence.

The medical experts concluded the applicant suffered only minor injuries and was not disabled from working.

The application for income replacement benefits was dismissed.

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

The applicant brought a motion for interim benefits pending the arbitration hearing and sought production of the insurer's claims file.

The arbitrator found that the applicant failed to attend a scheduled insurer examination, entitling the insurer to suspend benefits for that period.

The arbitrator dismissed the motion for interim benefits, finding the applicant had not established a prima facie case for entitlement given the conflicting medical evidence and lack of cross-examination.

The arbitrator also made several production orders, requiring the applicant to produce medical records from one year pre-accident and the insurer to produce non-privileged portions of its claims file.

The Applicant was injured in a motor vehicle accident and sought income replacement benefits after the Insurer terminated them.

The Insurer argued the Applicant could return to her pre-accident employment as a bartender.

The Arbitrator found the Applicant suffered a Grade II whiplash injury and was substantially unable to perform the essential tasks of her demanding pre-accident job, which included repetitive bending, reaching, and lifting.

The Applicant was awarded income replacement benefits and interest, but was ordered to pay the Insurer's arbitration expenses for the first day of the hearing due to her failure to appear.

The Applicant was injured in a motor vehicle accident and received income replacement benefits.

He sought an adjustment to his net weekly income based on the 1996 indexation percentage, despite having received benefits for less than one year at that time.

The Arbitrator held that under subsection 79(2) of the Statutory Accident Benefits Schedule, the Applicant was not entitled to the 1996 indexation percentage because he had been receiving benefits for less than one year.

The Arbitrator also awarded the Applicant his arbitration expenses for the period between June 16, 2000 and December 11, 2000, finding that his conduct did not unduly prolong the proceedings and his delay in accepting a settlement offer was reasonable.