Eric K. Grossman

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

The insurer denied medical rehabilitation and housekeeping expenses beyond 104 weeks and denied indexation of income replacement benefits.

On a preliminary issue, the arbitrator found that while the insurer failed to offer the optional indexation benefit when the applicant chose the transitional coverage option, the arbitrator lacked jurisdiction to order a remedy.

However, the arbitrator held that temporal limits do not apply to the transitional provisions under subsection 70(3) of the Schedule, entitling the applicant to claim supplementary medical and rehabilitation benefits beyond 104 weeks.

The appellant appealed an arbitration order finding that she was not an 'insured person' under the respondent's automobile insurance policy.

The appellant had submitted an application for accident benefits to the respondent, who was the first insurer to receive a completed application.

The respondent denied the claim on the basis of coverage, arguing she was not an insured person.

The Director of Arbitrations allowed the appeal, holding that under the Priorities Regulation (O. Reg. 283/95), the first insurer to receive a completed application must pay benefits pending the resolution of any priority dispute.

The Director found that the arbitrator erred in treating the issue as a coverage dispute rather than a priority dispute, and that the respondent was obliged to respond to the claim and could only shift responsibility by following the procedures in the Priorities Regulation.

The appellant, a pedestrian struck by a vehicle, appealed an arbitrator's decision dismissing his claim for weekly income benefits.

The appellant had returned to work for several years before being laid off due to lack of work.

The Director's Delegate upheld the arbitrator's finding that the appellant failed to prove his injuries continuously prevented him from engaging in suitable employment, as required by section 12(5)(b) of the SABS-1990, and failed to rebut the presumption of ineligibility under section 16(2) arising from his extended return to work.

The appeal was dismissed.

The applicant sought judicial review of decisions by an Arbitrator and the Director's Delegate, which found he was not injured in an 'accident' as defined in the Statutory Accident Benefit Schedule 1996.

The applicant, a taxicab driver, was struck on the head with a rock by an assailant while in his cab.

The Arbitrator found his injuries were caused solely by the assault and not by striking any part of the vehicle, thus failing the causation test for an 'accident'.

The Divisional Court held that the standard of review was patent unreasonableness and found the Tribunal's decisions were not only reasonable but correct.

The application for judicial review was dismissed.

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

He returned to his pre-accident employment for over three years before being laid off due to lack of work, and later worked another job for six months before being laid off again.

He subsequently claimed weekly income benefits, arguing he was continuously disabled.

The arbitrator dismissed the application, finding that the applicant's successful return to suitable employment for several years demonstrated he was not continuously prevented from engaging in suitable employment as required by section 12(5)(b) of the Schedule.

Claims for a special award and assessment fees were also dismissed.

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

He returned to work for several years before being laid off and claiming benefits again.

The insurer argued his return to work disqualified him as he was not 'continuously prevented' from engaging in suitable employment under s. 12(5)(b) of the Schedule.

The arbitrator held that whether the applicant was continuously prevented from working is a question of fact requiring full evidence, and that under s. 16(2), the applicant bears the burden of rebutting the presumption that his return to work for more than 90 days makes him ineligible for further benefits.

The parties cross-appealed an arbitration decision regarding statutory accident benefits following a motor vehicle accident.

The insured appealed the denial of interest on medical and rehabilitation benefits awarded at arbitration, arguing they were overdue.

The Director's Delegate dismissed this ground, holding that under the SABS-1996, benefits are not overdue prior to adjudication if a Designated Assessment Centre (DAC) concludes they are not reasonable and necessary.

The insurer appealed the award of s. 24 assessment expenses, arguing the insured had unreasonably refused to attend insurer examinations.

The Director's Delegate allowed the insurer's appeal in part, rescinding the award for two assessments because the insured used them to thwart the insurer's legitimate assessment requests.

The insured was awarded an additional $990 for a psychological assessment after proving collateral benefits were exhausted.

The insured's vehicle became stuck on an icy hill.

A passerby offered to help and got behind the wheel while the insured walked to the back to push.

Before she could push, the vehicle slid down the hill.

The insured walked down the icy road towards her vehicle, slipped, and broke her arm.

The insurer appealed the arbitrator's decision that the injury was an 'accident' under the Statutory Accident Benefits Schedule.

The Director's Delegate dismissed the appeal, finding that the insured's efforts to extricate her vehicle from a road hazard directly caused her injury, and the entire sequence of events constituted a single incident where the use or operation of the automobile was the dominant feature.

The applicant, a taxi driver, was stabbed by a passenger during a robbery and applied for statutory accident benefits.

The insurer initially paid income replacement benefits but later terminated them, arguing the incident was not an 'accident' under the Schedule.

The arbitrator found that the event setting the chain of causation in motion was an assault, not the use or operation of an automobile, and therefore the applicant was not involved in an 'accident'.

The arbitrator also held that the insurer did not waive its right to deny coverage by initially paying benefits, as there was no conscious intention to abandon a known right.

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

The insurer alleged it terminated his weekly income benefits when he returned to work and argued his subsequent application for arbitration was barred by the two-year limitation period.

The arbitrator found that while notice to the applicant's lawyer constituted notice to the applicant, the notice provided was not a clear and unequivocal refusal of benefits because it contradictorily stated the claim was accepted in its entirety.

Therefore, the limitation period had not expired, and the applicant was permitted to proceed to arbitration.

The appellant, a taxicab driver, was assaulted and struck on the head with a rock by a passenger during an attempted robbery.

He applied for statutory accident benefits, which were denied on the basis that the incident was not an 'accident' under section 2(1) of the SABS-1996.

The Arbitrator found that the vehicle was merely the location of the assault and did not directly cause the impairment.

On appeal, the Director's Delegate upheld the Arbitrator's decision, concluding that the assault, not the use or operation of the automobile, was the direct cause of the impairment.

The appeal was dismissed, but the respondent was ordered to pay the appellant's appeal expenses.

The applicant sought statutory accident benefits after breaking her arm when she slipped and fell on an icy road while walking back to her vehicle, which had slid into a snowbank after getting stuck.

The insurer denied benefits, arguing the incident was not an 'accident' under the Statutory Accident Benefits Schedule.

The arbitrator applied the purpose and causation tests, finding that the use or operation of the vehicle was involved and directly caused the injury, as the slip and fall was a normal and reasonably foreseeable risk of motoring in the circumstances.

The preliminary issue was resolved in favour of the applicant.

The Applicant sought to withdraw her claim for income replacement benefits from arbitration to pursue it in court, where she could seek relief from forfeiture for failing to attend an insurer's medical examination.

The arbitrator refused to allow the Applicant to split her case between two forums due to the risk of inconsistent results and increased costs.

However, the arbitrator permitted the Applicant to withdraw her entire application for arbitration without terms or conditions, finding that both parties contributed to the confusion regarding the issues in dispute and that the arbitration was not frivolous or vexatious.

The appellant brought a motion alleging institutional bias against the adjudicators of the Financial Services Commission of Ontario.

The motion was previously adjourned on conditions, including that the appellant pay $500 in expenses to the respondent.

The appellant failed to pay the expenses or provide submissions explaining the default.

The Director's Delegate dismissed the bias motion due to the appellant's deliberate refusal to comply with the prior order, finding that allowing the motion to continue would bring the administration of the appeal process into disrepute.

The appellant's agent requested an adjournment of the appeal proceedings to await the outcome of an application for intervener status in a separate case involving allegations of institutional bias at FSCO.

The Director's Delegate granted the adjournment on strict conditions, including that the appellant properly file the intervention application, notify the Attorneys General of a constitutional challenge, and pay $500 in expenses thrown away to the respondent insurer due to the late notice of the adjournment request.

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

The insurer terminated her income replacement benefits on February 4, 1998.

The applicant applied for mediation on June 16, 1999, but the application was returned by FSCO due to deficiencies.

The applicant did not correct the deficiencies until August 15, 2000, well after the two-year limitation period had expired on February 4, 2000.

The arbitrator found that the applicant failed to commence a valid mediation within the prescribed time limit and could not retroactively cure the defect to revive the original application.

The arbitration was dismissed as time-barred.

The insured was involved in two motor vehicle accidents and claimed statutory accident benefits from two insurers.

The arbitrator made various orders regarding income replacement benefits, attendant care, and repayment of overpaid benefits.

Both the insured and the second insurer appealed.

The Director of Arbitrations allowed the appeals in part, finding that the arbitrator erred in applying the partial inability test to extend income replacement benefits beyond the period the insured met the substantial inability test, and erred in refusing to decide the claim for lost and damaged items.

The remaining grounds of appeal were dismissed.

The applicant taxicab driver was assaulted by a passenger who struck him on the head with a rock in an attempted robbery.

Following the assault, the taxicab rolled into a ditch.

The applicant sought statutory accident benefits, which the insurer denied on the basis that the incident was not an 'accident' under the Schedule.

The arbitrator found that while the use of the taxicab met the purpose test, the injuries were not directly caused by the use or operation of the vehicle.

The vehicle was merely the location of the attempted robbery, and the intervening act of the assault was the direct cause of the impairment.

The application was dismissed.

The insurer requested that the insured's agent be excluded from representing her on appeal, arguing that he was incompetent and failed to comply with his duties, relying on the arbitrator's negative comments about his conduct at the initial hearing.

The Director's Delegate reviewed the principles for excluding an agent, noting that it is a severe measure meant to protect the proper administration of justice and the represented party's interests.

While expressing concern over the agent's past conduct, the Delegate concluded that excluding him at this preliminary stage was not warranted, but required the agent to file a signed acknowledgment from the insured confirming her informed choice to use an unlicensed agent.

The applicant was injured in a motor vehicle accident when he was nine years old.

Upon turning sixteen, he applied for statutory accident benefits.

The insurer denied the claim, arguing that because more than 156 weeks had passed since the accident, the more onerous post-156 week test applied.

The applicant argued that the pre-156 week test should apply initially upon his turning sixteen.

The arbitrator held that the pre-156 week test under subsection 13(1) of the Schedule applies first when an insured turns sixteen, regardless of the time elapsed since the accident, to avoid anomalous results based on the insured's age at the time of the accident.