Susan Naylor

The appellant appealed an arbitrator's decision upholding the termination of his weekly income benefits at the 156-week mark by the respondent insurer.

The central issue was whether the appellant met the disability test under section 12(5)(b) of the Statutory Accident Benefits Schedule, which requires that the injury continuously prevents the insured from engaging in any suitable occupation.

The appellant argued that the arbitrator erred in relying on the evidence of his treating physiatrist, who testified for the insurer, and in finding that suitable work was available.

The Director's Delegate dismissed the appeal, finding no error in the arbitrator's reliance on the physiatrist's evidence or the conclusion that the appellant was capable of light or sedentary work.

The appellant was awarded his reasonable appeal expenses.

The insurer appealed an arbitration order requiring it to pay income replacement benefits (IRBs) pending the resolution of a dispute over loss of earning capacity benefits (LECBs).

The Director's Delegate held that under the Statutory Accident Benefits Schedule, an insurer's obligation to pay IRBs does not automatically cease when it makes an offer of zero LECBs.

The appeal was dismissed, but the order was modified to require payment of IRBs only up to the date of the appeal decision, as the underlying dispute had been moved to the courts.

The appellant appealed an arbitrator's decision that allowed only a portion of his claimed physical rehabilitation and transportation expenses following a motor vehicle accident.

The Director's Delegate upheld the arbitrator's findings that the extended treatment hours claimed were not reasonable or required, and that the evidence for transportation expenses was insufficient.

The request for a special award was denied as it was not pursued at arbitration.

The arbitrator's order regarding arbitration expenses was varied to reflect the parties' agreement for two-and-a-half days of hearing.

The appeal was otherwise dismissed.

The Motor Vehicle Accident Claims Fund (MVAC) appealed an arbitration order requiring it to pay various expenses for R.W., who suffered a severe brain injury in a motorcycle accident and resided in a supportive group home.

The Director's Delegate upheld the arbitrator's findings that R.W.'s rent, mandatory program fees, and transportation costs were reasonable and necessary care and rehabilitation expenses under the Statutory Accident Benefits Schedule.

The Delegate reversed the award for personal care items and confectionary due to a lack of medical evidence.

The special award against MVAC for unreasonably refusing to pay the core expenses was upheld.

The appellant, Algoma Mutual Insurance Co., appealed a decision involving the respondent.

On consent of the parties, the Appeals Delegate ordered that the appeal be dismissed.

The parties agreed that the order is final and not subject to further appeal, variation, revocation, or judicial review.

The appellant was injured in a snowmobile accident while receiving temporary total disability benefits from the Workers' Compensation Board for a prior workplace injury.

He appealed an arbitrator's decision calculating his weekly income benefits under the Statutory Accident Benefits Schedule by averaging his employment income over the full 52 weeks preceding the accident, without including his WCB benefits as income from employment.

The Director's Delegate dismissed the appeal, confirming that the statutory language requires averaging over the full 52 weeks and that WCB benefits do not constitute income from employment under the applicable Schedule.

The claim for a special award was also dismissed.

The appellant appealed an arbitrator's decision denying his claim for income replacement benefits under the Statutory Accident Benefits Schedule.

The appellant claimed he had a legitimate contract of employment as a sales representative before the accident.

The Director's Delegate upheld the arbitrator's finding that the evidence did not establish a genuine employment contract, dismissing the income replacement claim.

However, the appeal was allowed in part to award the appellant the full $1,670 cost of a psycho-vocational assessment, finding it was a reasonable expense recommended by his treating doctors.

The insurer's cross-appeal for repayment of benefits was dismissed.

The insurer appealed an arbitrator's preliminary ruling that the insured's application for arbitration was not time-barred, despite the arbitrator ultimately dismissing the insured's claim for additional benefits on the merits.

The insured brought a motion to dismiss the appeal for mootness.

The Director's Delegate dismissed the appeal, finding that it raised no concrete dispute between the parties and that the insured had no stake in the outcome.

The arbitrator's order was confirmed and the insured was awarded appeal expenses.

The insurer appealed an arbitration order finding that the insured's application for arbitration was not time-barred.

The insurer had terminated the insured's weekly income benefits and provided oral, but not written, notice of its decision.

The Director's Delegate dismissed the appeal, holding that under the Insurance Act and the Statutory Accident Benefits Schedule, an insurer must provide written notice of a refusal to pay benefits to trigger the two-year limitation period.

The Director's Delegate also rejected the insurer's argument that the insured was estopped from relying on the lack of written notice, finding insufficient evidence that the insurer continued to rely on any agreement to forgo written notice.

The appellant insurer appealed an arbitrator's decision finding that the respondent pedestrian and her cohabitant were not spouses, which would have shifted liability for her accident benefits to the cohabitant's insurer.

The respondent and her cohabitant had lived together for over a decade but maintained separate finances, did not share a bedroom, and denied being romantically involved.

The Director's Delegate dismissed the appeal, finding no error in the arbitrator's application of the Molodowich criteria or his conclusion that the relationship was a close friendship rather than a conjugal one.

The insurer appealed an arbitrator's decision ordering it to pay a $10,000 special award for unreasonably withholding statutory accident benefits.

The insured had suffered a back injury in a motor vehicle accident, and the insurer denied benefits based on a pre-existing condition.

The Director's Delegate dismissed the appeal, finding that the arbitrator's conclusion was supported by the evidence.

The insurer had maintained a stubborn and inflexible position, failing to re-evaluate the claim even after receiving MRI results and medical reports confirming an organic basis for the insured's ongoing symptoms.

This document contains two separate decisions by the Director's Delegate.

In the first, the applicant was ordered to produce clinical notes and records of her doctor to the insurer.

In the second, an appeal regarding a priority dispute between two insurers, the Director's Delegate upheld the arbitrator's finding that an elderly couple living together for over a decade were not 'spouses' under the Statutory Accident Benefits Schedule, as they did not live in a conjugal relationship.

The appellant insurer appealed an arbitration decision holding it responsible for paying the respondent's statutory accident benefits, valuing the respondent's fringe benefits for income calculation, and refusing to deduct CPP disability benefits.

The Director's Delegate dismissed the appeal, finding that the respondent was not a 'named insured' under the garage policy of his father's company despite being listed in an endorsement.

The Delegate also upheld the arbitrator's factual findings regarding the valuation of the respondent's payment-in-kind and confirmed that CPP benefits were not deductible.

The appellant was injured in a motor vehicle accident and claimed weekly income benefits under s. 12(1) of the Statutory Accident Benefits Schedule, arguing she was substantially unable to perform the essential tasks of her family meat business.

The arbitrator dismissed the claim, finding the appellant was not disabled from her work and questioning the credibility of her evidence.

On appeal, the appellant sought to re-argue the facts and alternatively claim caregiver benefits under s. 13.

The Director's Delegate dismissed the appeal, holding that an appeal is not a re-hearing of the facts, the arbitrator made no palpable error in assessing credibility, and the appellant could not change the parameters of her claim to s. 13 on appeal.

The arbitrator's decision limiting chauffeur expenses to minimum wage was also upheld due to lack of proof of lost income.

The appellant insurer appealed an arbitrator's order that included a special award under subsection 282(10) of the Insurance Act.

On consent of the parties and based on written submissions, the Director's Delegate ordered that the paragraph of the arbitrator's order requiring the insurer to pay a special award of 35% be rescinded.

The balance of the appeal was dismissed.

The insurer appealed an arbitrator's decision awarding the self-employed claimant weekly income benefits of $550.52 and interest on overdue payments.

The insurer argued the claimant failed to prove his income with reliable documentation and that interest should not run until sufficient documentation was provided.

The Director's Delegate dismissed the appeal regarding the benefit amount, finding the arbitrator was entitled to accept the claimant's reconstructed invoices and credible testimony.

The appeal regarding interest was varied to clarify that under section 24 of the Schedule, interest on overdue payments runs from 10 days after the completed application is received, regardless of when supporting documentation is provided.

The appellant appealed an arbitrator's refusal to award her arbitration expenses following a two-day hearing regarding her claim for a 'Kenko Sleep System'.

The arbitrator had dismissed the claim, finding it had little merit and was not supported by credible medical evidence.

The Director's Delegate dismissed the appeal, finding no error in the arbitrator's exercise of discretion to deny expenses.

The appellant was injured in a motor vehicle accident and received weekly income benefits for 156 weeks.

The insurer terminated benefits under the post-156 week test, which requires the insured to be continuously prevented from engaging in any suitable occupation or employment.

The arbitrator upheld the termination, finding the appellant failed to prove he was unable to perform other less strenuous work suited to his background, and that there was insufficient evidence linking his depression to the accident.

On appeal, the Director's Delegate confirmed the arbitrator's decision, concluding that the appellant did not meet the burden of establishing disability within the meaning of the Schedule.

The appellant, a high school student, was injured in a motor vehicle accident before starting a summer job.

The insurer paid weekly income benefits based on the prospective job's earnings for the duration of the summer contract, but reduced the benefits thereafter.

The Director's Delegate allowed the appeal, holding that under the Statutory Accident Benefits Schedule, once a person qualifies for benefits based on a definite job offer, the gross weekly income calculated from that contract establishes the benefit rate for the entire duration of the disability, not just the term of the contract.

The appellant appealed an arbitration order denying his claim for ongoing weekly income benefits and a higher benefit rate following a motor vehicle accident.

The insurer had terminated benefits after the appellant failed to attend a scheduled medical examination.

The Director's Delegate upheld the arbitrator's findings that the appellant lacked credibility, failed to prove substantial inability to perform his pre-accident employment as a roofer, and provided insufficient evidence to calculate a higher benefit rate.

The appeal was dismissed with no appeal expenses payable.