Susan Naylor

The Applicant was injured in a motor vehicle accident while riding his motorcycle and sought statutory accident benefits.

The Insurer terminated his weekly disability benefits, prompting the Applicant to apply for arbitration.

The Applicant claimed he was employed "under the table" at the time of the accident and thus qualified for income benefits under section 12 of the Schedule.

The Arbitrator found the Applicant's evidence regarding his employment lacked credibility and concluded he was not employed at the time of the accident.

Furthermore, the Arbitrator determined the Applicant was not entitled to non-earner benefits under section 13, as he was able to perform the bulk of his pre-accident activities of daily living.

The application was dismissed, and the Applicant was denied his arbitration expenses due to the lack of merit in his case.

The respondent was injured while exiting a TTC bus and subsequently attended a functional capacities evaluation (FCE) to obtain clearance to return to work.

During the FCE, she sustained new injuries due to improper lifting techniques.

The arbitrator found these new injuries were sustained 'as a result of' the accident and awarded ongoing income replacement benefits.

The insurer appealed, arguing the new injuries were not 'directly caused' by the use or operation of the automobile and that the therapist's actions constituted an intervening cause.

The Director's Delegate dismissed the appeal, holding that injuries sustained during a reasonable rehabilitation assessment for accident-related impairments are a direct consequence of the accident, absent an intervening cause that disengages the connection.

The appellant insurer appealed an arbitrator's decision including various employer-funded employment benefits in the calculation of the respondent's gross income from employment for the purpose of determining income replacement benefits under the Statutory Accident Benefits Schedule.

The Director's Delegate allowed the appeal in part, holding that life insurance premiums, weekly indemnity premiums, pension contributions, pay equity adjustments, and uniform allowances were properly included in gross income.

However, the Director's Delegate found that the arbitrator erred in including the employer's contributions to the Canada Pension Plan and Employment Insurance, as well as accrued sick day benefits.

The cross-appeal regarding the exclusion of accrued vacation pay was dismissed.

The appellant appealed an arbitration decision denying him ongoing income replacement benefits, the cost of a TENS machine, a higher mileage rate, and an increased special award following a motor vehicle accident.

The Director's Delegate upheld the arbitrator's finding that the appellant's ongoing disability was caused by severe pre-existing physical and psychological conditions, and that the accident did not materially contribute to his disability beyond March 1997.

The appeal was dismissed with respect to the income replacement benefits, TENS machine, and special award.

However, the Director's Delegate varied the arbitration order to allow mileage expenses at a rate of 22 cents per kilometre, up from the 13 cents paid by the insurer.

The insurer appealed a preliminary decision holding that the insured's application for mediation was not time-barred.

The insurer had stopped paying income replacement benefits after receiving a report from a designated assessment centre stating the insured was no longer disabled.

The insurer argued the two-year limitation period began when it stopped payments.

The Director's Delegate dismissed the appeal, finding that the insurer must clearly and unequivocally communicate its refusal to pay benefits, including providing information about the dispute resolution procedure, to trigger the limitation period.

The insurer failed to prove it had done so more than two years before the mediation application.

The appellant, who suffered a severe brain injury in a motor vehicle accident, appealed an arbitration decision dismissing his claim for payment of 'non-legal' rehabilitative services provided by a law clerk at his legal counsel's firm.

The arbitrator had found that the claim was not proven because the law clerk's dockets did not reliably distinguish between legal and non-legal services, and that the services were redundant given the extensive support provided by the appellant's professional case manager.

The Director's Delegate dismissed the appeal, finding no error in the arbitrator's assessment of the evidence and concluding that the arbitrator reasonably found the expense to be unproven and unnecessary.

The insurer appealed an arbitrator's decision awarding the insured his full arbitration expenses.

The insurer had been largely successful at the arbitration and had made a qualifying offer to settle prior to the hearing.

The Director's Delegate found that the arbitrator erred in law by misapprehending the terms of the settlement offer, mistakenly believing it required the insured to give up all future benefits.

In reassessing the expenses, the Director's Delegate noted that while the insurer's offer was serious and the insurer was mostly successful, the insured's case had some merit based on the medical evidence.

The appeal was allowed in part, and the expenses award was varied to entitle the insured to two-thirds of his reasonable arbitration expenses.

The appellant was injured in a motor vehicle accident and received income replacement benefits (IRBs) until they were terminated by the insurer prior to the 104-week mark.

At arbitration, the arbitrator ordered IRBs to be paid for an additional period but found the appellant was no longer substantially disabled from her employment thereafter.

The arbitrator did not address the insurer's obligation to make a loss of earning capacity benefit (LECB) offer.

On appeal, the Director's Delegate held that because the appellant qualified for IRBs at the 104-week mark, the insurer was statutorily required to promptly deliver an LECB offer, even if the ultimate benefit amount might be zero.

However, the Delegate declined to order the continuation of IRBs pending the LECB offer, finding no statutory authority for such an extension once the procedural requirements for termination had been met.

The applicant sought to vary or revoke an appeal order and arbitration orders that dismissed her claims for statutory accident benefits as time-barred.

The Director's Delegate found an error in the previous orders, as they failed to consider whether the applicant had a 'reasonable excuse' under s. 59(4) of the Statutory Accident Benefits Schedule for not submitting a timely application for other disability benefits.

The application for variation was allowed in part, and the issue of entitlement to other disability benefits, including the reasonable excuse issue, was remitted to an arbitrator for a new hearing.

The insurer appealed an arbitrator's decision awarding the insured income replacement benefits and a $2,500 special award following a minor car wash collision.

The insurer argued the arbitrator erred procedurally by allowing a key medical expert to testify by telephone and substantively by misapprehending the medical evidence regarding the insured's pre-existing conditions.

The Director's Delegate dismissed the appeal regarding income replacement benefits, finding no procedural unfairness and sufficient evidentiary basis for the arbitrator's causation findings.

However, the Director's Delegate rescinded the special award, concluding the arbitrator erred by raising it on his own initiative without providing the insurer adequate notice or opportunity to respond, and by failing to properly assess whether the insurer's withholding of specific medical expenses was unreasonable.

The appellant appealed an arbitration order denying his claim for ongoing income replacement benefits and chiropractic expenses following a motor vehicle accident.

The arbitrator had found that the appellant's inability to work as a carpenter was due to pre-existing, degenerative back and shoulder problems, rather than the accident.

On appeal, the Director's Delegate upheld the arbitrator's findings on causation and the denial of benefits, concluding there was no error of law and the findings were supported by the evidence.

However, a claim for other rehabilitation expenses that was inadvertently overlooked at arbitration was remitted for determination.

The appellant appealed an arbitrator's decision denying her arbitration expenses following an unsuccessful claim for full death benefits.

The arbitrator had found that the appellant's claim to be the sole spouse was without merit and that her conduct, along with her counsel's, unreasonably prolonged the hearing.

The Director's Delegate dismissed the appeal, holding that the arbitrator has broad discretion regarding expenses and did not err in her cumulative assessment that the appellant's unreasonable conduct warranted a denial of expenses.

The insurer appealed an arbitrator's decision that an excluded driver endorsement was valid but only took effect after the first of two motor vehicle accidents.

The insureds cross-appealed, arguing the endorsement was entirely invalid.

The Director's Delegate allowed the cross-appeal, finding that the endorsement was not validly executed because the insured and the excluded driver signed in the wrong places, and the insured, who faced a language barrier, did not have the requisite intent to exclude her husband.

The insurer's appeal was dismissed.

AXA Insurance Company appealed an arbitration order awarding Mario Rocca income replacement benefits beyond the 104-week mark and a $10,000 special award.

Rocca cross-appealed the calculation of his benefits regarding commission income.

The Director's Delegate found that despite the arbitrator's adverse credibility findings against Rocca, there was sufficient objective medical evidence, including an MRI showing a large disc herniation, to support the conclusion that he was disabled from the physical aspects of his pre-accident job.

The Director's Delegate also upheld the special award, finding the insurer unreasonably reduced benefits to the minimum level without an objective basis.

Both the appeal and cross-appeal were dismissed.

The appellant insurer appealed an arbitrator's decision awarding a $10,000 death benefit to each of the deceased's parents under s. 25(2) 5. i of the Statutory Accident Benefits Schedule (SABS-1996).

The insurer argued that only a single $10,000 payment was payable in respect of the death of a dependant, relying on previous decisions under earlier SABS regimes.

The Director's Delegate dismissed the appeal, finding that the subtle shift in language in SABS-1996 contemplated that more than one person could qualify for the payment, entitling both parents to the benefit.

The insured was involved in a motor vehicle accident and claimed rehabilitation expenses.

She applied for arbitration and subsequently commenced a court action claiming the same expenses.

The insurer appealed an arbitrator's order that allowed the insured to proceed with arbitration if she amended her court action to exclude those expenses.

The Director's Delegate allowed the appeal in part, dismissing the arbitration application because the insured had elected to proceed in court and the statutory scheme precludes pursuing the same claims in both forums.

The insurer's request for reimbursement of its arbitration assessment fee under s. 282(11.2) of the Insurance Act was denied because the insurer was already seeking that relief by way of a counterclaim in the court action.

The insurer appealed an arbitrator's interim order requiring it to produce all adjuster's notes prior to June 1, 1999, except for those made during a prior mediation.

The insured argued the notes were relevant because she was claiming a special award for unreasonable denial of benefits.

The Director's Delegate allowed the appeal in part, finding that a claim for a special award does not automatically entitle an insured to the complete file.

The production order was narrowed to the period between when the insurer first received notice of the disputed claims and the commencement of the mediation.

The insurer appealed an arbitrator's decision awarding the insured weekly income benefits beyond the 156-week mark and a $20,000 special award.

The insured had suffered physical and psychological injuries in a severe motor vehicle accident and was unable to continue working.

The Director's Delegate upheld the arbitrator's finding that the insured was continuously prevented from engaging in suitable employment, noting the insurer failed to provide evidence of alternative suitable jobs while the insured adduced substantial medical evidence of disability.

The special award was also confirmed because the insurer unreasonably terminated benefits and disregarded the recommendations of its own medical experts.

The insurer appealed an arbitrator's decision that it was not entitled to deduct CPP disability benefits from the insured's weekly income benefits and that the insured's application for arbitration was not time-barred.

The Director's Delegate dismissed the appeal, confirming that CPP disability benefits are not deductible from statutory accident benefits.

Furthermore, the Director's Delegate held that the insurer's adjustment of the benefit amount to reflect the CPP payments did not constitute a 'refusal to pay' the benefit claimed, and therefore the two-year limitation period under the Insurance Act had not been triggered.

The appellant appealed an arbitrator's decision denying her ongoing weekly income benefits beyond a six-month extension and refusing a special award.

The arbitrator had found that the appellant would have been fit for full-time work had she continued her prescribed exercise program, and that her failure to do so was the sole cause of her continuing disability.

The Director's Delegate upheld the decision, finding that the arbitrator did not improperly import mitigation principles but correctly considered rehabilitation efforts in determining whether the appellant met the statutory definition of disability.

The Delegate also upheld the refusal of a special award, finding no error in the arbitrator's conclusion that the insurer's termination of benefits was not unreasonable.

The appeal was dismissed, with partial expenses awarded to the appellant.