Stewart McMahon

The appellant was injured in a motor vehicle accident and applied for income replacement benefits.

The arbitrator determined the appellant was self-employed and attributed 50% of his closely held family company's profits to him, with the remainder attributed to his wife and children who also worked in the business.

The appellant appealed, arguing that 100% of the profits should be attributed to him as the sole voting shareholder and key person.

The Director's Delegate dismissed the appeal, finding the arbitrator properly considered the share structure, expectation of profit, relative contributions, and degree of risk of all family members.

The appeal regarding the applicable claim code was also dismissed.

The appellant appealed a preliminary arbitration order that stayed his arbitration hearing until he attended two insurer examinations.

The appellant argued the stay should not have been granted because the insurer had defaulted on its statutory obligation to pay for rehabilitation benefits pending the hearing.

The Director's Delegate dismissed the appeal, finding it was not clear on the evidence that the insurer had breached the 'pay pending' rules, and upheld the arbitrator's finding that the examinations were reasonably necessary.

The appellant appealed an arbitration order dismissing her claim for the cost of a medical assessment under section 57(1) of the Statutory Accident Benefits Schedule.

The assessment was arranged by her former counsel two years after the insurer stopped funding her treatment, and there was no evidence that the resulting report was used to advance a claim for benefits or that the recommended treatment was pursued.

The Director's Delegate upheld the arbitrator's finding that the appellant failed to prove the assessment was reasonably incurred for the purposes of the Regulation.

The appeal was dismissed with expenses awarded to the insurer.

The appellant appealed an arbitration decision that denied his claim for income replacement benefits and limited his housekeeping and home maintenance expenses to $100 per week.

The appellant argued he was self-employed as a property developer and manager, but the Director's Delegate upheld the Arbitrator's finding that he was not employed and earned no income at the time of the accident.

The Delegate also upheld the $100 weekly cap on housekeeping expenses.

However, the appeal regarding arbitration expenses was allowed in part, reducing the costs awarded to the respondent by $500 to account for the appellant's initial success before settlement offers were made.

The appellant was injured in a motor vehicle accident and received statutory accident benefits until the insurer terminated them.

The insurer argued the appellant's subsequent application for arbitration was time-barred under the two-year limitation period.

Applying the Supreme Court of Canada's decision in Smith v. Co-operators General Insurance Co., the Director's Delegate found that the insurer's termination notice was deficient because it failed to inform the appellant of the right to sue or arbitrate if mediation failed.

Consequently, a valid refusal was not given, the limitation period was not triggered, and the appellant's right to arbitrate was not barred.

The insured sustained injuries in two separate motor vehicle accidents three months apart, insured by Allstate and Progressive respectively.

Following a disastrous surgery years later, the insured required attendant care and supplementary medical benefits.

A previous arbitration decision found both insurers liable for income replacement benefits but did not explicitly structure the payment of medical and attendant care benefits.

On appeal, the Director's Delegate held that the issue of structuring these benefits was not res judicata.

Applying principles of equitable contribution among insurers, the Delegate ordered Allstate and Progressive to share the costs of the supplementary medical and attendant care expenses equally, subject to their respective policy limits, as both accidents materially contributed to the insured's condition and neither insurer had priority over the other for these specific expenses.

The respondents were injured in a motor vehicle accident in California and claimed statutory accident benefits from the Motor Vehicle Accident Claims Fund.

The Fund denied the claim, arguing it was not responsible for out-of-province accidents, and later challenged the arbitrator's jurisdiction to decide the issue.

The arbitrator ruled she had jurisdiction, and the Fund sought leave to appeal this preliminary order before the remaining issues were decided.

The Director's Delegate denied the motion for leave to appeal, finding that proceeding with the appeal could lead to multiple appeal proceedings and unnecessary delay, and deferred the appeal until the remaining issues, including the existence of a potential insurer, were resolved.

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

After two years, the insurer transitioned the applicant to loss of earning capacity benefits (LECBs).

The insurer later attempted to argue that the applicant's disability was unrelated to the accident.

The arbitrator held that the insurer was precluded from raising a causation defence because it had paid IRBs to the 104-week mark without protest and had already begun paying LECBs.

The arbitrator determined the applicant's residual earning capacity at various stages, awarding LECBs based on a 30-hour work week initially, and a 20-hour work week after the three-year review.

The arbitrator also awarded supplementary medical expenses and a $3,000 special award for the insurer's unreasonable refusal to fund psychological counselling.

The applicant was injured when struck by a vehicle and sought payment from his insurer for a multidisciplinary assessment conducted by DEAHY Medical Assessments Inc., totalling $2,461.

The insurer denied the benefit, arguing the assessments were unnecessary, duplicative, and unreasonably priced.

The arbitrator found that the physiotherapy and functional capacity assessments were reasonable and payable, but the orthopaedic assessment was unnecessary as the applicant should have sought a report from his treating surgeon.

The arbitrator ordered the insurer to pay $1,498 plus interest, and dismissed the applicant's claim for a special award.

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

She subsequently fell down stairs, exacerbating her knee injury.

The insurer terminated benefits at the 104-week mark without making a loss of earning capacity benefit (LECB) offer, arguing the ongoing disability was caused by the fall, not the accident.

The arbitrator held that the insurer could not challenge the applicant's qualification for benefits after paying them without protest for 104 weeks.

Furthermore, applying the Amos test, the arbitrator found the subsequent fall was a direct consequence of the accident-induced knee weakness, unbroken by any negligence.

The applicant was awarded an LECB offer, specific medical and housekeeping benefits, and a special award for the insurer's delay in paying settlement funds.

The applicants were injured in a motor vehicle accident and applied for statutory accident benefits from State Farm.

State Farm denied the claims on the basis that the policy had been cancelled prior to the accident.

The applicants initially argued that State Farm was required to pay benefits pending a priority dispute with another insurer under Regulation 283/95.

At the hearing, the applicants conceded that the policy had been cancelled and consented to an order dismissing their claims against State Farm, intending to pursue the other insurer instead.

The arbitrator dismissed the claims on consent without expenses.

The applicant claimed she was struck by a motor vehicle while walking and sought statutory accident benefits, including weekly 'other disability' benefits, housekeeping, attendant care, and prescription expenses.

The insurer terminated benefits after approximately one year, arguing the applicant did not suffer a partial inability to carry on a normal life.

The arbitrator found that while the applicant continued to suffer from various ailments, they were largely attributable to pre-existing psychological difficulties rather than the accident.

The arbitrator concluded the applicant did not meet the threshold of a substantial inability to engage in her pre-accident activities.

The claims for weekly benefits, housekeeping, and prescriptions were dismissed, but a modest $120 was awarded for expenses incurred by her sister while attending the hospital.

The applicant was involved in two motor vehicle accidents and sought ongoing income replacement and supplementary medical benefits (chiropractic treatments) from the insurer.

The insurer terminated benefits, arguing the applicant was no longer disabled or that any disability was due to pre-existing conditions or the second accident.

The arbitrator found that the applicant's pre-existing back and shoulder injuries from prior workplace falls were the true cause of his inability to work as a carpenter, and the accidents did not significantly exacerbate his condition.

The claim for ongoing chiropractic expenses was also dismissed as the applicant failed to prove the treatments were reasonable or effective in light of a negative DAC assessment.

The applicant was injured in two motor vehicle accidents in 1995 and sought statutory accident benefits, including caregiver benefits, housekeeping expenses, and medical/rehabilitation costs.

The insurer terminated caregiver benefits in 1996 based on surveillance and medical assessments suggesting the applicant was exaggerating her symptoms.

The arbitrator dismissed the claim for ongoing caregiver benefits, finding the applicant's evidence unreliable and her limitations overstated.

However, the arbitrator partially granted the claims for housekeeping expenses, recognizing some ongoing impairment, and ordered the insurer to pay outstanding medical, chiropractic, and transportation expenses.

The applicant was injured when she fell on a TTC bus.

She applied for statutory accident benefits, including income replacement benefits and various medical and rehabilitation expenses.

The insurer terminated income replacement benefits based on a multidisciplinary DAC assessment.

The arbitrator found the applicant to be a poor historian prone to exaggeration and deceit, and preferred the evidence of the IME and DAC assessors over her treating physiatrist.

The claim for ongoing income replacement benefits was dismissed as the applicant failed to prove she was substantially unable to perform her duties as a housekeeper and nanny.

Claims for psychological treatment, massage therapy, a lumbosacral support, and some taxi fares were allowed, while the remaining claims were dismissed.

The applicant applied for arbitration seeking income replacement benefits and reimbursement for an occupational therapy assessment following a motor vehicle accident.

Shortly after, the applicant's representative withdrew the application and ceased acting for him.

The applicant failed to respond to communications or attend the pre-hearing and the hearing regarding withdrawal conditions.

The arbitrator granted the withdrawal and ordered the applicant to pay the insurer's expenses of $600.32, finding that while the claim for the assessment was not necessarily frivolous, the applicant's failure to communicate or attend unnecessarily lengthened the proceeding.

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

The insurer terminated income replacement benefits, alleging the applicant failed to attend a medical examination and was malingering.

The arbitrator found that the insurer improperly terminated benefits before obtaining a Designated Assessment Centre report, entitling the applicant to benefits until the report's release.

However, the arbitrator concluded the applicant grossly exaggerated his physical and cognitive symptoms, relying on surveillance evidence and medical inconsistencies, and denied ongoing income replacement benefits.

The arbitrator also awarded limited supplementary medical and attendant care benefits, and a special award due to the insurer's unreasonable delay in initial payments and refusal to fund certain treatments.

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

He later signed a full and final release in exchange for a $50,000 lump sum payment.

He subsequently sought further benefits, arguing the agreement should be set aside due to misrepresentation, undue influence, and unconscionability.

The Arbitrator found that the insurer did not misrepresent the potential for future benefits, did not exercise undue influence, and that the settlement was not unconscionable.

The agreement was held to be binding, and the application for further benefits was dismissed.

The applicant was injured in a motor vehicle accident and received statutory accident benefits, which the insurer terminated after three years.

She applied for arbitration seeking reinstatement of weekly benefits and homemaker services.

The arbitrator found that while the applicant suffered from a significant mobility impairment and chronic pain that justified the reinstatement of 12 hours per week of homemaker services, her disability was not so pervasive as to continuously prevent her from engaging in substantially all of her usual activities.

Therefore, the claim for ongoing weekly benefits was dismissed.

The applicant was awarded her expenses for the arbitration.

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

The insurer terminated weekly income benefits at the 156-week mark based on surveillance showing the applicant occasionally selling plants at a market.

At the hearing, the insurer conceded entitlement but disputed the quantum of the weekly benefit and the applicant's claim for a special award.

The arbitrator calculated the applicant's pre-accident income from his self-employed plant business and set the weekly benefit at $501.60.

The arbitrator also found that the insurer unreasonably terminated benefits at the 156-week mark without seeking updated medical information or making sufficient inquiries, and ordered a special award of $2,000.