Edmund W. Kent

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

The insurer claimed it terminated the benefits and sent a notice of assessment, but the applicant, who had limited English skills, denied receiving it.

The insurer raised a preliminary issue that the applicant's arbitration request was barred by the two-year limitation period under s. 281(5) of the Insurance Act.

The arbitrator found that the insurer failed to prove it had delivered a clear and unequivocal notice of termination to the applicant.

As a result, the limitation period had not begun to run, and the applicant was not precluded from proceeding to arbitration.

The applicant was injured in a motor vehicle accident and received weekly income benefits for three years.

The insurer terminated benefits, arguing she was no longer substantially unable to perform the essential tasks of her employment and lacked motivation to return to work.

The arbitrator found that the applicant suffered from post-traumatic stress disorder, depression, anxiety, and chronic pain as a result of the accident.

Based on medical and psychological evidence, the arbitrator concluded that the applicant's physical and psychological limitations continuously prevented her from engaging in any suitable occupation or employment.

The applicant was awarded ongoing weekly income benefits and interest.

The applicant was injured while a passenger on a TTC streetcar.

She did not notify her husband's insurer of her intention to apply for accident benefits until 11 months after the accident, well past the 30-day requirement under section 59 of the Statutory Accident Benefits Schedule.

The insurer denied the claim due to late notice.

The applicant argued she had a reasonable excuse because her husband, fearing increased premiums, refused to provide his insurance details despite her repeated requests.

The arbitrator found that the applicant's excuse was reasonable given the family's patriarchal dynamic and her inability to obtain the information otherwise.

The insurer's motion to dismiss the claim was denied, allowing the applicant to proceed to arbitration on the merits.

The applicant was injured in a motor vehicle accident and received income replacement benefits for 104 weeks.

The insurer then offered a loss of earning capacity benefit of zero and ceased paying income replacement benefits.

The applicant requested a Residual Earning Capacity Assessment at a Designated Assessment Centre (REC DAC) and sought reinstatement of her income replacement benefits pending the report.

The REC DAC report failed to determine a residual earning capacity.

The arbitrator held that under section 23 of the Statutory Accident Benefits Schedule, the insurer is not authorized to substitute a loss of earning capacity benefit until the release of a valid REC DAC report.

The insurer was ordered to pay ongoing income replacement benefits from the date of termination, subject to review by the hearing arbitrator.

The applicant was injured in a motor vehicle accident and sought supplementary medical benefits, an education disability benefit, loss of earning capacity benefits, and a special award from her insurer.

The insurer denied the claims, arguing that the applicant's temporomandibular joint (TMJ) dysfunction and psychological issues were not caused by the accident.

The arbitrator found that the TMJ symptoms were caused by the accident and ordered the insurer to pay for related treatments, but denied the claim for psychological assessments as they were self-referred and not requested from the insurer beforehand.

The claims for education disability and loss of earning capacity benefits were dismissed because the applicant did not meet the statutory criteria.

The request for a special award was also denied as the insurer's conduct was not unreasonable.

The applicant was injured in a motor vehicle accident and received income replacement benefits until the insurer terminated them at the 104-week mark.

The applicant brought a motion for interim benefits and a special award, arguing the insurer failed to follow the termination provisions of the Statutory Accident Benefits Schedule.

The arbitrator found that the insurer unreasonably withheld benefits by failing to properly transition the applicant to loss of earning capacity benefits or continue the termination procedure.

The arbitrator ordered the insurer to pay interim income replacement benefits, ongoing loss of earning capacity benefits, and a 10 percent special award for unreasonable delay.

The applicant was injured in a motor vehicle accident and received statutory accident benefits until the insurer terminated weekly income benefits.

The applicant sought arbitration for ongoing weekly income benefits and housekeeping expenses, claiming disability due to chronic pain and fibromyalgia.

The arbitrator preferred the evidence of the insurer's psychological expert, finding that the applicant's pain behavior was not organically based and was inadvertently reinforced by her family.

The arbitrator concluded the applicant was not disabled from working and dismissed the claim for ongoing income benefits.

However, the arbitrator awarded $4,780 for housekeeping and babysitting expenses incurred during a reasonable recovery and transition period.

The applicant was injured in a motor vehicle accident in December 1991 and received weekly income benefits until May 1992, when he returned to work and the insurer terminated benefits.

In February 1995, after injuring his back at work, the applicant sought reinstatement of benefits, which the insurer refused on the basis of the two-year limitation period.

The arbitrator held that the applicant was precluded from proceeding to arbitration under section 281(5) of the Insurance Act and section 26(1) of the Statutory Accident Benefits Schedule, as the application was commenced more than two years after the insurer's clear refusal to pay benefits in June 1992.

The arbitrator found that the applicant's return to work after the termination of benefits did not suspend the limitation period.

The applicant was injured in a motor vehicle accident and received income replacement benefits until the insurer terminated them.

The applicant brought a motion for interim benefits, arguing the insurer failed to comply with the benefit stoppage provisions under section 64 of the Statutory Accident Benefits Schedule.

The arbitrator held that to obtain interim benefits, an applicant must establish a prima facie case for entitlement and a sense of urgency.

The arbitrator found that the medical evidence raised the possibility that the applicant's cognitive problems resulted from non-accident related causes, such as age-related dementia.

As the applicant failed to present sufficient evidence or legal arguments to establish a prima facie case for entitlement, the motion for interim benefits was dismissed.