Eric K. Grossman

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

The insurer denied benefits based on collateral deductions.

The applicant applied for arbitration solely on the issue of collateral benefits deduction.

The insurer sought to add the issue of entitlement to the arbitration.

The arbitrator held that under the amended section 282(3) of the Insurance Act, the arbitrator shall determine all issues in dispute, whether raised by the insured or the insurer.

The insurer was permitted to raise the issue of entitlement at the hearing.

The Applicant sought ongoing weekly income benefits following a minor motor vehicle accident.

The Insurer terminated benefits after 10 months.

The Arbitrator found the Applicant's claims of disabling physical and psychological pain to be unsupported by objective medical evidence and contradicted by surveillance footage showing him engaging in normal activities without restriction.

The claim for ongoing benefits was dismissed.

The Applicant was awarded half of his arbitration expenses and the return of a $2,000 assessment fee, as the claim was not found to be frivolous or vexatious.

The appellant insurer appealed an arbitration decision finding it responsible for paying statutory accident benefits to the claimant.

The claimant was injured while a passenger in a vehicle insured by the respondent insurer.

The claimant applied for benefits from the appellant insurer on the basis that she was the spouse of its named insured.

The arbitrator found that the claimant and the named insured had cohabited in a relationship of some permanence and were therefore spouses under the Insurance Act.

On appeal, the Director's Delegate upheld the arbitrator's finding, concluding that there was sufficient evidence to support the determination of cohabitation despite the parties maintaining separate residences.

The appeal was dismissed, with a new issue regarding policy interpretation reserved for further submissions.

The insured was injured in a motor vehicle accident and received weekly income benefits until the insurer terminated them at the three-year mark.

The insured applied for mediation within the two-year limitation period but did not apply for arbitration until more than two years after the benefits were terminated.

The arbitrator held that the limitation period applied on a rolling basis, barring only claims for periods ending more than two years before the application.

On appeal, the Director's Delegate reversed, holding that the two-year limitation period under section 281(5) of the Insurance Act runs from the insurer's refusal to pay benefits, not from the date each payment becomes overdue.

The insured's claim for further weekly income benefits was therefore entirely time-barred.

The applicant sought reinstatement of weekly income benefits following a minor single-vehicle accident.

The insurer terminated benefits based on medical reports and surveillance evidence showing the applicant performing physical tasks.

The arbitrator found the applicant lacked credibility, noting extensive pre-existing physical and psychological problems, including marital difficulties and prior injuries.

The arbitrator concluded the accident did not materially contribute to her ongoing issues and dismissed the claim for benefits.

Finding the arbitration to be an abuse of process, the arbitrator ordered the applicant to pay the insurer's $2,000 assessment fee.

The applicant was injured in a motor vehicle accident and received weekly income benefits until he returned to work.

He later stopped working due to shoulder pain and underwent surgery.

He applied for weekly income benefits for the period he was off work.

The arbitrator found that the accident significantly contributed to the aggravation of his pre-existing shoulder instability.

However, the applicant only proved he was disabled from performing the essential tasks of his employment from July 21, 1994, when his orthopaedic surgeon first examined him, to June 19, 1995, when he returned to work.

The applicant was awarded benefits for that period, along with interest and expenses, subject to a minor reduction for late production of documents.

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

The applicant applied for arbitration more than two years after the termination.

The insurer raised a preliminary issue that the application was barred by the two-year limitation period under section 281(5) of the Insurance Act.

The arbitrator held that the cause of action for ongoing weekly benefits accrues at the end of each two-week pay period.

Therefore, claims for pay periods ending more than two years before the application for arbitration were statute-barred, but claims for subsequent periods were not.

The applicant was seriously injured in a motor vehicle accident while a passenger in a vehicle insured by State Farm.

She claimed statutory accident benefits.

The issue was whether she was the spouse of the owner of another vehicle, insured by Allstate, at the time of the accident.

The arbitrator found that the applicant and the Allstate insured, who were the natural parents of a child and had resumed a relationship including weekend cohabitation prior to the accident, met the extended definition of 'spouse' under the Insurance Act.

Consequently, Allstate was held liable to pay the applicant's accident benefits.

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

After mediation failed, the applicant applied for arbitration but subsequently failed to provide required medical and financial documentation, lost contact with his representative, and did not attend the hearing.

The arbitrator dismissed the claims for failure to prove entitlement and found the applicant's conduct constituted an abuse of process.

The applicant was ordered to pay $2,000 to each insurer for their assessment fees pursuant to section 282(11.2) of the Insurance Act.

The Insurer brought a motion for the production of accident benefit claims files from Economical Mutual Insurance Company relating to two third parties, alleging that the Applicant's claim was part of a scheme involving fraudulent employment information.

The Arbitrator ordered the production of the requested files, excepting any documents relating to the setting of claims reserves, and directed that notice be given to the affected third parties and the other insurer to allow them to make submissions.

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

The insurer terminated benefits based on surveillance video allegedly showing the applicant working.

The applicant disputed his identity in the videos, prompting a preliminary issue hearing.

After reviewing the video evidence, photographs, and witness testimony, the arbitrator concluded the applicant was indeed the individual depicted in the September 15, 1993 surveillance tape.

The applicant's request for hearing expenses was denied because his late admissions unnecessarily prolonged the proceedings.

The applicant sought assessment of expenses related to the expert testimony of his family doctor at an arbitration hearing.

The doctor billed for preparation, travel, and attendance time.

The arbitrator held that under section 5(1)2 of Ontario Regulation 664, expert witness expenses are limited to the reasonable time the expert is in attendance at the hearing site, and do not include pre-arbitration preparation or travel time.

The insurer was ordered to pay $112.50 for the 45 minutes the doctor spent at the hearing.

The applicant failed to attend a scheduled medical examination without a reasonable excuse, resulting in a $250 no-show fee assessed by the physician.

The insurer deducted this fee from the applicant's ongoing weekly accident benefits.

The applicant applied for arbitration to dispute the deduction.

The arbitrator held that there is no statutory authority under the Insurance Act or the Statutory Accident Benefits Schedule allowing an insurer to set off a no-show fee against an insured's entitlement to benefits.

The insurer was ordered to repay the $250 with interest, and the applicant was awarded expenses.

The applicant was injured in a motor vehicle accident and received benefits from the insurer, which were later terminated.

The applicant applied for arbitration but failed to appear at the hearing, subsequently withdrawing her claim.

The insurer sought a dismissal of the applicant's claims, a determination of its own claims for repayment, and an assessment of costs.

The arbitrator held that the applicant's claims were not dismissed and the insurer's claims for repayment could not be determined independently of the applicant's claims.

However, the arbitrator awarded $1,000 to the insurer under section 282(11.2) of the Insurance Act, finding that the applicant's conduct amounted to an abuse of process.

The applicant, a 70-year-old retiree, was injured in a motor vehicle accident and suffered a compression fracture of the L4 vertebrae.

The insurer paid weekly benefits under section 13 of the Statutory Accident Benefits Schedule but terminated them on April 21, 1993, arguing the applicant was no longer substantially unable to perform his essential pre-accident tasks.

The arbitrator determined the applicant's essential tasks included personal care, limited household chores, and a daily walk.

The arbitrator found that the applicant remained substantially unable to perform these tasks until June 8, 1993, when he was discharged from a physiotherapy program having resumed about 70% of his normal daily regimes.

The applicant was awarded weekly benefits for the closed period from April 21 to June 8, 1993, plus interest and arbitration expenses.