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Coverage dispute regarding whether applicant is an 'insured' must be decided by private arbitrator in priorities dispute.
The applicant was injured in a motor vehicle accident and applied to the insurer for statutory accident benefits.
The insurer denied coverage and initiated a priorities dispute, arguing another insurer was responsible.
The insurer sought a preliminary determination at the Financial Services Commission of Ontario (FSCO) on whether the applicant was an 'insured' under the Schedule.
The arbitrator held that distinguishing between coverage disputes and priority disputes is artificial and contrary to the legislative scheme.
The issue of whether the applicant is an insured must be determined by a private arbitrator as part of the priorities dispute under O. Reg. 283/95, not by a FSCO arbitrator.
Assault by a co-worker outside a truck is not an 'accident' for statutory accident benefits.
The applicant sought statutory accident benefits after being assaulted by a co-worker who dragged him out of his truck and threw him against it.
The insurer denied benefits on the basis that the incident was not an 'accident' under section 2 of the Statutory Accident Benefits Schedule.
The arbitrator agreed, finding that the applicant's injuries were caused by the assault, not by the use or operation of the automobile.
As there was no accident, the insurer was not required to pay benefits pending dispute resolution under subsection 59(5).
Arbitration dismissed as abandoned after applicant failed to attend pre-hearings or contact counsel.
The applicant commenced an arbitration for statutory accident benefits but subsequently failed to attend scheduled pre-hearings or maintain contact with his counsel.
The insurer brought a motion to dismiss the arbitration as frivolous, vexatious, or commenced in bad faith under Rule 68.1 of the Dispute Resolution Practice Code.
The arbitrator granted the motion, finding the application had effectively been abandoned, and awarded the insurer $500 in expenses.
Insurer ordered to provide specific particulars of its response to applicant's special award claim.
In a pre-hearing conference regarding a dispute over statutory accident benefits, the applicant sought the insurer's reasons for continuing to deny income replacement benefits and its response to her claim for a special award.
The insurer objected, arguing the request amounted to discovery, which is not provided for in the Commission's rules.
The arbitrator ordered the insurer to provide specific particulars of its response to the special award claim within 20 days of receiving the applicant's particulars, finding that meaningful pleadings are necessary to facilitate a fair and expeditious dispute resolution process.
