Suesan Alves

The insurer brought a preliminary motion seeking to compel the insured to attend psychiatric and neuropsychological assessments under section 42 of the Statutory Accident Benefits Schedule.

The insured opposed the motion, arguing the request was not reasonably necessary and was made too close to the scheduled arbitration hearing.

The arbitrator found that while earlier medical recommendations provided a reasonable basis for the assessments, the insurer's delay of over two years in arranging them was unreasonable and prejudicial to the insured.

The arbitrator also rejected the insurer's argument that a recent psychiatric report raised a new diagnosis warranting fresh assessments.

The motion was dismissed.

A partner at a treatment centre commenced arbitration applications for statutory accident benefits in the names of two former patients.

The patients had previously settled their claims and paid the treatment centre's account in full.

The arbitrator found that the authorizations filed by the treatment provider were forged and that the patients had not authorized the proceedings.

Finding that the treatment provider commenced the arbitration on his own account and abused the tribunal's process, the arbitrator amended the style of cause to make the provider the applicant and ordered him to pay the expenses of the patients and the insurer before being permitted to withdraw the applications.

The applicant was injured in a rear-end motor vehicle accident and sought payment for 99 active rehabilitation treatment sessions and four treatment plans.

The insurer denied the treatment plans, arguing the duration and cost were excessive.

The arbitrator found that the applicant required supervised active rehabilitation to return to his pre-accident heavy labour job and that the duration of the program was reasonable.

However, the arbitrator reduced the hourly rate from the claimed $150 to $60 per session, noting the treatment was provided in a group setting rather than one-on-one.

The arbitrator also awarded interest on overdue payments and a $1,000 special award, finding the insurer unreasonably withheld payments by unilaterally reducing the rate for approved treatment without a valid basis.

The applicant was injured in two motor vehicle accidents in 1995 and sought ongoing income replacement benefits (IRBs) and rehabilitation benefits from the insurer.

The arbitrator found that the applicant had a legitimate contract of employment as a truck driver trainee prior to the second accident and was substantially unable to perform the essential tasks of that employment due to injuries sustained in the accident, specifically heterotopic bone formation affecting his ability to sit for prolonged periods.

The applicant was awarded IRBs based on the truck driving contract, as well as funding for a vocational assessment at Goodwill Industries and case management services.

The applicant's claim for a higher IRB rate based on his pre-accident work as a taxi driver was dismissed due to a lack of reliable income evidence.

The applicant was injured in a motor vehicle accident and sought supplementary medical and rehabilitation benefits.

The insurer rejected the claims and argued that the applicant was time-barred from proceeding to arbitration because she applied outside the two-year limitation period under section 281(5) of the Insurance Act.

Applying the Supreme Court of Canada's decision in Smith v. Co-operators Insurance Company, the arbitrator found that the insurer's notices of refusal did not provide full details of the dispute resolution process as required by section 71 of the Statutory Accident Benefits Schedule.

Consequently, there was no valid refusal, the limitation period never began to run, and the applicant was permitted to proceed to arbitration.

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

The insurer argued that the applicant's claims for income replacement benefits and supplementary medical benefits were time-barred under section 281(5) of the Insurance Act and section 72 of the Statutory Accident Benefits Schedule.

The arbitrator found that the insurer's initial communications did not constitute a clear and unequivocal refusal of a crystallized claim for income replacement benefits.

The arbitrator also held that an insurer cannot issue a blanket refusal in advance for future supplementary medical benefits.

The applicant was permitted to proceed to arbitration for her income replacement benefits claim and for supplementary medical benefits claimed after March 20, 1998.

The applicant was injured in two motor vehicle accidents and claimed various statutory accident benefits from her insurer.

The insurer argued she had signed a full and final release for her income replacement benefits, which also barred her claim for loss of earning capacity benefits (LECBs).

The arbitrator found the release only applied to income replacement benefits and that the applicant was entitled to an offer for LECBs because she was substantially unable to perform the essential tasks of her pre-accident employment at the 104-week mark.

The arbitrator also awarded supplementary medical expenses, housekeeping and attendant care benefits, and a special award against the insurer for unreasonably withholding certain benefits.

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

The Fund brought a motion arguing that a FSCO arbitrator lacked jurisdiction to interpret section 6 of the Motor Vehicle Accident Claims Act and section 268 of the Insurance Act, and that the arbitration duplicated a Superior Court action.

The arbitrator dismissed the motion, finding that section 20(2) of the Insurance Act grants arbitrators exclusive jurisdiction to determine all questions of fact or law in proceedings before them, including interpreting the relevant statutes.

The arbitrator also found that the arbitration for accident benefits did not duplicate the tort action in the Superior Court.

The insurer brought a motion seeking production of the applicant's examination for discovery transcript from a related tort action to test his credibility at an arbitration hearing.

The applicant opposed production, relying on the deemed undertaking rule.

The arbitrator dismissed the motion, holding that only the court in which the tort action was commenced has the jurisdiction to grant relief from the implied or deemed undertaking rule.

The arbitrator disagreed with previous FSCO decisions that found concurrent jurisdiction to grant such relief under the Insurance Act.

The applicant claimed medical and rehabilitation benefits following a motor vehicle accident.

The insurer denied the treatment plans without scheduling a medical and rehabilitation designated assessment centre (DAC) as required by section 38 of the Statutory Accident Benefits Schedule.

The applicant brought a preliminary motion arguing the insurer was deemed to have admitted entitlement due to this procedural breach.

The arbitrator found the insurer failed to comply with the denial provisions, but held that based on existing case law, the breach raised an evidentiary rather than a jurisdictional question.

The arbitrator declined to decide the consequences of the breach on a preliminary basis, ordering the matter to proceed to a full hearing.

The applicant sought interest on an award of expenses previously made against the insurer following an arbitration for statutory accident benefits.

The insurer disputed the arbitrator's jurisdiction to award interest on expenses.

The arbitrator held that the Insurance Act and the Statutory Accident Benefits Schedule do not grant an arbitrator the authority to award interest on expenses, as interest is a substantive right requiring express statutory authorization.

However, the arbitrator noted that the applicant could enforce the expenses order in the Superior Court of Justice to obtain post-judgment interest under the Courts of Justice Act.

Despite being unsuccessful on the motion, the applicant was awarded $350 in expenses because the insurer had delayed payment of the original expenses award and the issue raised was novel.

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

The Fund purported to terminate his other disability benefits in May 1997.

The applicant applied for mediation more than two years later.

The Fund argued the application was time-barred under section 281(5) of the Insurance Act.

The arbitrator found that the Fund's notice of refusal was not clear and unequivocal, and that the Fund failed to comply with the mandatory termination requirements of section 64 of the Statutory Accident Benefits Schedule.

Therefore, the limitation period never began to run, and the applicant was not precluded from proceeding to arbitration.

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

The insurer terminated her income replacement benefits, arguing she had recovered and could return to her pre-accident employment as a meat packer.

The arbitrator found that the applicant suffered from chronic pain syndrome and a major depressive disorder caused by the accident, rendering her substantially unable to perform the essential tasks of her employment.

The arbitrator preferred the evidence of the applicant's treating practitioners and experts over the insurer's assessors.

The applicant was awarded ongoing income replacement benefits, supplementary medical expenses, and interest on overdue benefits.

The applicant claimed a $50,000 death benefit following the death of a pedestrian struck by a motor vehicle, alleging she was his common-law spouse.

The insurer disputed the spousal relationship.

The arbitrator applied the family law criteria for determining a conjugal relationship and found that the applicant failed to establish on a balance of probabilities that she and the deceased lived together in a conjugal relationship continuously for at least one year, or that they demonstrated a settled intention to treat her son as a child of their family.

The claim for a death benefit was dismissed.

The applicant sought statutory accident benefits following two motor vehicle accidents in June 1995 and July 1996.

The insurers disputed his claims for income replacement benefits, supplementary medical expenses, rehabilitation expenses, attendant care benefits, other pecuniary losses, and housekeeping expenses.

The first insurer also sought repayment of benefits.

The arbitrator found that the applicant was entitled to income replacement benefits from the second insurer for a specific period, as well as certain supplementary medical expenses, attendant care benefits, and other pecuniary losses.

The claims for rehabilitation and housekeeping expenses were dismissed.

The arbitrator also ordered the applicant to repay the first insurer for a period of income replacement benefits due to misrepresentation regarding his pre-accident abilities and receipt of short-term disability benefits.

The applicant was injured in a motor vehicle accident and claimed an income replacement benefit based on self-employment as an Amway distributor.

The insurer paid an other disability benefit.

The arbitrator found that the applicant was not self-employed at the time of the accident but qualified for an income replacement benefit because she had been employed as a child care worker within the 156 weeks before the accident.

The arbitrator concluded that the applicant's physical and psychological impairments, including an inability to control her anger, rendered her substantially disabled from working as a child care worker.

The applicant was awarded income replacement benefits, with a credit to the insurer for other disability benefits paid.

The claim for a special award was dismissed.

The applicant sought interim expenses pending the completion of an arbitration for statutory accident benefits.

The hearing was delayed for six months due to the insurer's counsel's schedule.

The arbitrator applied the Bernicky criteria, noting the applicant's financial inability to carry the expenses of the arbitration and the bona fide issues raised.

The arbitrator ordered the insurer to pay $3,100.50 in interim expenses for medical reports and records, subject to a final order on expenses at the conclusion of the hearing.

The applicant sought an assessment of his expenses and a special award following an arbitration where he succeeded on claims for housekeeping expenses and interim benefits.

The insurer disputed the legal fees account as excessive.

The arbitrator found the applicant's counsel's preparation time reasonable given the complexity of the issues and the insurer's late request for an adjournment, which resulted in costs thrown away.

The arbitrator awarded $18,180 in legal fees plus GST.

The arbitrator denied the claim for a special award under section 282(10) of the Insurance Act, finding that the provision applies to the late payment of statutory accident benefits, not to a bill of expenses.

The applicants claimed statutory accident benefits following an alleged motor vehicle accident with a taxi.

The insurer denied the claims, arguing the accident never occurred, and sought repayment of benefits already paid.

The arbitrator found the applicants' evidence regarding the events leading up to the accident and the accident itself to be implausible and riddled with inconsistencies.

Consequently, the applicants failed to prove on a balance of probabilities that the accident occurred, and their claims for benefits were dismissed.

However, the insurer's claim for repayment was also dismissed, as it failed to provide clear and convincing evidence of wilful misrepresentation or fraud.

The arbitrator issued an amended arbitration order to correct a typographical error in a previous decision.

The words 'future statutory accident benefits' were substituted with 'further statutory accident benefits' in paragraphs 1 and 2 of the order regarding the applicants' claims against the insurer.