Eric K. Grossman

The appellant's appeal from a preliminary arbitration decision regarding statutory accident benefits was previously rejected.

The parties could not agree on the legal expenses of the appeal, leading to this expense hearing.

The Director's Delegate found that the respondent was completely successful and that the appeal was unnecessary, as the appellant had conceded the adjudicator lacked jurisdiction to grant the requested relief from forfeiture.

The respondent was awarded its claimed legal expenses of $1,949.96.

The appellant sought to appeal an arbitrator's preliminary decision which found that her claims for housekeeping services and catastrophic impairment designation were barred by the two-year limitation period under the Insurance Act.

The arbitrator had also ruled that he lacked jurisdiction to grant relief from forfeiture under section 129 of the Insurance Act.

The Director's Delegate rejected the appeal pursuant to Rule 51.2(c) of the Dispute Resolution Practice Code, finding that it was an appeal from a preliminary order that did not finally decide the issues in dispute, and that the appellant had not raised a valid question of law or demonstrated grounds to justify an immediate appeal.

The applicant was injured in a motor vehicle accident and applied for statutory accident benefits.

The insurer terminated certain benefits, and the applicant applied for arbitration.

The applicant subsequently withdrew her application to pursue a market conduct complaint, and later refiled after the complaint was dismissed.

The insurer argued the refiled claims were barred by the two-year limitation period under s. 281(5) of the Insurance Act.

In this preliminary issue hearing, the arbitrator found the withdrawal and refiling was an abuse of process but permitted the refiling to avoid prejudice.

The arbitrator then analyzed each claim, finding that the limitation period barred several claims where the insurer had provided a valid, unequivocal refusal more than two years prior.

Claims without a valid refusal or where the insurer's conduct suggested ongoing consideration were permitted to proceed.

The arbitrator also dismissed the applicant's request to set aside a prior settlement agreement.

The applicant was injured while riding a rented all-terrain vehicle (ATV) in British Columbia and applied for statutory accident benefits from her mother's Ontario automobile insurer.

The insurer denied the claim on the basis that the ATV was not an 'automobile' under the Statutory Accident Benefits Schedule.

The arbitrator held that the definition of 'automobile' under subsection 224(1) of the Ontario Insurance Act, which includes vehicles required to be insured under 'any Act', refers exclusively to Acts of the Ontario Legislature.

Because the ATV was not required to be insured under Ontario law, it was not an automobile, and the applicant was not involved in an 'accident' within the meaning of the Schedule.

Four individuals injured in a motor vehicle accident received treatment from a chiropractor, who submitted OCF-23 forms to the appellant insurer.

The appellant argued these forms did not constitute a 'completed application for benefits' under s. 2 of O. Reg. 283/95.

The arbitrator and application judge found that the forms provided sufficient particulars to reasonably assist the insurer with processing the application and assessing the claim.

The Court of Appeal dismissed the appeal, confirming that an application need not be on a specific form to trigger the 'pay now, dispute later' obligation, provided it contains sufficient information to commence adjusting the claim.

The applicant, a self-employed bagel maker, claimed he lost his business due to physical and mental impairments sustained in a motor vehicle accident.

He sought income replacement benefits, attendant care, housekeeping, and a determination of catastrophic impairment due to a mental or behavioural disorder.

The insurer denied the claims, alleging the applicant was malingering.

The arbitrator found that while the applicant suffered from genuine psychological dysfunction, it predated the accident and was caused by pre-existing business, financial, and marital stressors.

The arbitrator concluded the applicant did not suffer a catastrophic impairment, failed to prove pre-accident self-employment income, and unreasonably withheld business records.

All claims were dismissed except for a small amount of incurred treatment expenses, for which a 50% special award was granted due to the insurer's unreasonable denial.

The applicant insurer sought judicial review of an arbitrator's refusal to declare a mistrial and recuse himself from a statutory accident benefits arbitration.

The applicant argued that the arbitrator's exposure to settlement offers and off-the-record discussions during an emotional outburst by the self-represented respondent created a reasonable apprehension of bias.

The Divisional Court dismissed the application, finding that the arbitrator's knowledge of settlement information did not automatically mandate a mistrial and that his handling of the situation did not raise a reasonable apprehension of bias.

The appellant was injured in a motor vehicle accident and received disability benefits until January 1997.

In January 2000, the respondent insurer sent a letter refusing further weekly benefits, outlining the dispute resolution process, and enclosing relevant sections of the Insurance Act.

In 2007, the appellant sought to amend his statement of claim to include a claim for income replacement benefits.

The motion was dismissed on the basis that the two-year limitation period had expired.

On appeal, the court held that the insurer's letter constituted a valid refusal that triggered the limitation period, as it adequately informed the appellant of the dispute resolution process.

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

The arbitration hearing was adjourned sine die to allow the insurer to seek judicial review of the arbitrator's refusal to recuse himself.

The insurer brought a motion to lift the adjournment order, while the applicant sought to resume the hearing and continue receiving interim attendant care benefits.

The arbitrator held that the arbitration should not be stayed indefinitely pending judicial review, as no formal stay had been granted by a court or the Director of Arbitrations.

The arbitrator ordered the hearing to resume at the first opportunity and directed the insurer to continue paying interim attendant care benefits of $400 per week until the hearing recommences, subject to repayment if the applicant is ultimately unsuccessful.

The applicant sought statutory accident benefits following a motor vehicle accident.

During the arbitration hearing, the insurer's counsel requested an adjournment and subsequently refused to participate further, citing an intention to seek judicial review of the arbitrator's refusal to recuse himself.

The arbitrator granted an adjournment but imposed conditions, including an order that the insurer immediately recommence paying the applicant an attendant care benefit of $400 per week, finding that the insurer's unilateral withdrawal prejudiced the unrepresented applicant.

During an arbitration hearing for statutory accident benefits, the applicant became hysterical and allegedly disclosed a settlement offer.

The insurer brought a motion for a mistrial and requested the arbitrator recuse himself, arguing the disclosure and the arbitrator's decision to remain in the room during the outburst compromised his impartiality.

The arbitrator dismissed the motion, finding that professional adjudicators are capable of disregarding irrelevant settlement information and that remaining in the room to ensure safety did not create a reasonable apprehension of bias.

The applicant sought to withdraw her application for arbitration regarding statutory accident benefits.

The insurer refused to consent and requested an expense hearing.

The arbitrator found that the applicant's representative, her husband acting without compensation, had complied with the requirements of Rule 70 of the Dispute Resolution Practice Code and permitted the withdrawal.

The arbitrator declined to award expenses to either party under Rule 75, finding that no aspect of the proceeding was improper, vexatious, or unnecessary, and ordered the parties to bear their own expenses.

In an arbitration for statutory accident benefits, the insurer sought to file an expert report on catastrophic impairment after the hearing had commenced, missing the 30-day deadline under Rule 39.1 of the Dispute Resolution Practice Code.

The insurer argued that a recent Court of Appeal decision constituted a change in law justifying the late filing.

The arbitrator rejected this argument, finding no change in the law that would constitute extraordinary circumstances.

Furthermore, the arbitrator held that the report, which offered an interpretation of the AMA Guides, usurped the core function of the arbitrator and was therefore inadmissible under the Mohan criteria.

The insurer appealed an arbitrator's decision awarding the insured person medical benefits and the cost of assessments and reports, arguing the arbitrator erred in law by relying on the evidence of a clinic director with a financial interest in the outcome and poor record-keeping practices.

The insured person cross-appealed the dismissal of claims for translation services and the offsetting of a misdirected payment.

The Director's Delegate found that the arbitrator's findings of fact regarding the medical benefits were supported by the evidence and did not constitute an error of law.

However, the Director's Delegate allowed the appeal in part, finding the arbitrator erred in awarding section 24 expenses for certain reports that served only as advocacy or were prepared after the treatment cut-off date.

The cross-appeal was dismissed.

The applicant's husband, a taxi driver, was stabbed to death by a passenger while operating his taxi.

The applicant applied for statutory accident benefits.

The insurer denied the claim on the basis that the death was not caused by an 'accident' as defined in the Schedule.

The arbitrator held that while the deceased was using the automobile for an ordinary purpose, the assault was an intervening act that broke the chain of causation and could not be considered a normal incident of the risk created by the use or operation of the vehicle.

The claim was dismissed.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for various medical treatments, medications, and the cost of reports and assessments.

The insurer denied the claims based on a DAC assessment that concluded further treatment was not reasonable or necessary.

The arbitrator found that the applicant's recovery was prolonged by pre-existing conditions and psychological issues, and that the multi-disciplinary treatments provided were reasonable and necessary up to a certain date.

The arbitrator awarded partial payment for the treatments and reports, and full payment for the medications.

The claim for a special award was dismissed as the insurer's reliance on its medical reports was not unreasonable.

The applicant was awarded interest and arbitration expenses.

The appellant insurer appealed an arbitration decision finding that the respondent's supplementary medical and rehabilitation benefits were not time-limited.

The Director's Delegate allowed the appeal, finding that the arbitrator erred in relying on external interpretive aids (brochures) to interpret the transitional provisions of the Statutory Accident Benefits Schedule.

The Director's Delegate held that the transitional provisions increased the monetary maximum for medical and rehabilitation benefits but did not eliminate the 10-year durational limit.

The arbitration order was varied to state that the respondent is not entitled to claim supplementary medical or rehabilitation benefits for a period in excess of ten years post-accident.

The respondent was injured in a motor vehicle accident and claimed an income replacement benefit under the Statutory Accident Benefits Schedule.

At the time of the accident, she had been employed for six weeks under a contract providing an annual salary of $29,000, but had only earned two weeks' pay in the four weeks prior to the accident.

The motion judge held that her gross annual income should be based on her contracted annual salary.

The Court of Appeal allowed the insurer's appeal, holding that the clear language of s. 8(3) of the Schedule required her gross annual income to be calculated by multiplying her actual gross income for the four weeks prior to the accident by 13.

The applicant applied for statutory accident benefits following a motor vehicle accident.

The insurer failed to file its Response to the Application for Arbitration within the 20-day time limit prescribed by the Dispute Resolution Practice Code.

The insurer brought a motion for an order extending the time for delivery of its Response nunc pro tunc.

The arbitrator applied the criteria for setting aside a default judgment, finding that the insurer's default was unintentional, the motion was brought promptly, and the applicant suffered no prejudice.

The motion was granted and the time for delivery of the Response was extended.

The applicant, who sustained catastrophic injuries in a motor vehicle accident, sought production of the insurer's complete accident benefits file and internal policy manuals regarding attendant care benefits.

The insurer objected to producing documents created after the date of the application for mediation, claiming privilege.

The arbitrator ordered the insurer to produce its complete file up to the date the application for arbitration was registered, finding that the insurer failed to establish litigation privilege for that period and that the applicant was entitled to disclosure of the insurer's thought process regarding a section 42 medical examination.

The arbitrator declined to order broad production of policy manuals, restricting it to those specifically referenced in the produced file or those the insurer intends to rely on at the hearing.