Arthur Ameis

The applicant was struck by a pickup truck while riding his bicycle, sustaining severe injuries to his left heel and ankle.

He applied for a determination of catastrophic impairment, which the insurer denied.

At arbitration, the arbitrator preferred the evidence of the applicant's experts, finding that his need for two crutches and a short leg brace resulted in a 55% Whole Person Impairment under the AMA Guides.

Furthermore, the arbitrator accepted that the applicant's chronic pain and depression resulted in a Class 4 marked impairment in at least one area of functioning.

The arbitrator concluded that the applicant sustained a catastrophic impairment under both paragraphs 2(1.2)(f) and (g) of the Schedule.

The applicant was injured in a motor vehicle accident and applied for a determination of catastrophic impairment.

The insurer's Designated Assessment Centre concluded she did not suffer a catastrophic impairment.

The arbitrator found that the applicant suffered a marked impairment in social functioning due to the accident, satisfying the definition of catastrophic impairment under section 2(1)(g) of the Schedule.

The arbitrator also assessed her physical impairments at 52% WPI, which combined with her psychological impairment would exceed the 55% threshold.

The applicant was awarded her expenses of the arbitration.

The insurer appealed an arbitration decision finding that the insured was catastrophically impaired under the Statutory Accident Benefits Schedule.

The insurer argued the arbitrator erred in finding the insurer's Designated Assessment Centre (MDAC) had a conflict of interest, in failing to order a new assessment, and in assigning whole person impairment (WPI) ratings for psychological and dental impairments.

The Director's Delegate dismissed the appeal, upholding the arbitrator's findings that MDAC failed to resolve a conflict of interest and failed to conduct a comprehensive assessment.

The Delegate confirmed the arbitrator had the authority to weigh the available evidence to determine the impairment ratings rather than ordering a new assessment, and found the 14% WPI for psychological impairment and 10% WPI for dietary restrictions were reasonably supported by the evidence and the AMA Guides.

The appellant appealed an arbitrator's decision denying her claim for a digital motion x-ray (DMX) expense and failing to address her claim for a special award following a motor vehicle accident.

The Director's Delegate upheld the arbitrator's finding that the DMX test was not reasonable or necessary under section 24 of the Statutory Accident Benefits Schedule, as it was conducted long after treatment ceased and was too remote from any potential benefits.

The Delegate varied the order to explicitly dismiss the claim for a special award, finding no evidence of insurer misconduct to justify it.

The appeal was otherwise dismissed.

The applicant sustained soft tissue injuries in a rear-end motor vehicle collision and sought statutory accident benefits, including caregiver benefits, housekeeping expenses, medical rehabilitation, and the cost of a digital motion x-ray (DMX).

The insurer denied the claims, arguing the applicant's injuries should have resolved within normal healing times.

The arbitrator found the applicant suffered a substantial inability to perform her pre-accident caregiver and heavier housekeeping duties for a limited period, awarding reduced amounts due to exaggerated claims.

The arbitrator also awarded partial medical and rehabilitation benefits, finding the applicant's pre-existing poor posture delayed her recovery beyond the standard guidelines.

The claim for the DMX test was dismissed, as the technique lacked general diagnostic approval in Canada, the expert promoting it lacked independence, and the test was conducted too remotely from the applicant's treatment period to be considered a reasonable expense.

The insurer appealed an arbitrator's decision finding that the claimant suffered a catastrophic impairment under the Statutory Accident Benefits Schedule following a motor vehicle accident.

The arbitrator relied on Glasgow Coma Scale (GCS) scores of 9 or less taken within the first hour of the accident.

The insurer argued the scores were confounded by intubation, seizures, and facial injuries, and were not taken within a 'reasonable period of time'.

The Director's Delegate dismissed the appeal, finding no palpable and overriding error in the arbitrator's factual findings that the early scores validly reflected brain impairment and were taken within a reasonable time.

The applicant was seriously injured in a motor vehicle accident and subsequently developed a severe addiction to crack cocaine.

He applied for catastrophic impairment status, attendant care benefits, and income replacement benefits.

The insurer argued the addiction pre-dated the accident and was not causally linked.

The arbitrator found that the applicant was a recreational user prior to the accident but the severe addiction was a direct result of the accident, likely due to a mild traumatic brain injury and an attempt to self-medicate.

The arbitrator concluded the applicant suffered a Class 4 marked impairment under the AMA Guides, meeting the definition of catastrophic impairment.

The applicant was awarded ongoing attendant care benefits of $5,056.80 per month and income replacement benefits of $256 per week.

The insurer brought a motion for an order permitting its medical expert to conduct an examination of the insured pursuant to section 42 of the Statutory Accident Benefits Schedule.

The insured, an 83-year-old man who suffered a catastrophic impairment in a motor vehicle accident, sought funding for home modifications to return home from a nursing home.

The medical/rehabilitation Designated Assessment Centre had failed to address the reasonableness and necessity of the treatment plans, instead improperly revisiting causation.

The arbitrator found that, given the DAC's failure to assess the treatment plans and the lack of a recent physical examination, the insurer's request for an examination was reasonable and necessary.

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

The insurer terminated weekly income benefits after 156 weeks.

The applicant sought ongoing benefits, claiming she was continuously prevented from working as a dressmaker due to chronic pain and fibromyalgia.

The arbitrator dismissed the claim for ongoing benefits, relying heavily on surveillance evidence that contradicted the applicant's reported functional limitations.

However, the arbitrator found that collateral benefits received by the applicant from private disability policies were not deductible from her pre-156 week income benefits, ordering the insurer to pay the shortfall with interest.

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

The insurer terminated her income replacement benefits, prompting the applicant to apply for arbitration.

Shortly before the hearing, the insurer reinstated the benefits and paid the arrears with interest.

The arbitration proceeded solely on the issue of whether the applicant was entitled to a special award under s. 282(10) of the Insurance Act.

The arbitrator found that the insurer acted unreasonably and engaged in flagrant misconduct by terminating benefits without meaningful medical evidence, ignoring overwhelming medical reports from its own assessors confirming the applicant's severe depression and disability, and improperly deducting collateral benefits.

The arbitrator awarded the maximum special award of 50% of the withheld benefits, amounting to $61,829.52.

The insurer applied to vary or revoke a 1996 arbitration order that required it to pay ongoing weekly income benefits to the respondent under the post-156 week disability test.

The respondent had suffered severe hip injuries in a 1990 motor vehicle accident.

The insurer presented evidence that since the original order, the respondent had achieved significant professional success as the lead vocalist and musical director of a gospel choir, including recording contracts, Juno awards, and film appearances.

The arbitrator found that the respondent's activities demonstrated she was fully capable of engaging in the occupation of a professional musician or choir director, and that her lack of remuneration was a lifestyle choice rather than a result of her disability.

The arbitrator concluded there was a material change in circumstances and revoked the order for ongoing benefits.

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

The applicant applied for arbitration, seeking ongoing weekly income benefits, transportation expenses, and a special award.

The arbitrator found that the applicant suffered from chronic pain and depression caused by the accident, which continuously prevented him from engaging in any suitable employment.

The arbitrator ordered the insurer to pay ongoing weekly income benefits and transportation expenses.

However, the arbitrator also ordered the applicant to repay an overpayment of income replacement benefits due to his receipt of collateral benefits, and denied the request for a special award.

The appellant appealed an arbitration decision dismissing her claim for income replacement benefits following a motor vehicle accident.

The arbitrator had rejected her claim on the basis that she was not employed at the time of the accident, relying in part on hearsay statements made by her alleged employer and a co-worker to an investigator.

On appeal, the Director's Delegate found that the arbitrator erred in relying on the hearsay evidence without the witnesses being called to testify.

However, the appeal was dismissed because the arbitrator's rejection of the appellant's employment evidence was supportable based on other significant inconsistencies and gaps in her own testimony.

The insurer appealed an arbitration decision that reinstated the insured's income replacement benefits and ordered a $7,500 special award.

The insured developed spasmodic torticollis following a rear-end motor vehicle accident.

The Director's Delegate upheld the arbitrator's refusal to stay the hearing for a late-scheduled independent medical examination, finding the insurer's delay unreasonable.

The Delegate also affirmed the arbitrator's conclusion that the accident materially contributed to the insured's condition, and upheld the special award on the basis that the insurer unreasonably relied on a qualified Designated Assessment Centre report without arranging necessary neurological follow-up.

The applicant was injured in a motor vehicle accident and, two weeks later, was assaulted and robbed at her workplace.

She claimed ongoing statutory accident benefits, arguing her disability stemmed from the car accident, while the insurer argued her ongoing issues were caused by the robbery.

The arbitrator found that both events significantly contributed to her condition, satisfying the causation requirement for accident benefits.

The applicant was awarded weekly income benefits for the first 156 weeks, as she was substantially disabled from her pre-accident employment.

However, she was denied benefits beyond 156 weeks because she was capable of engaging in suitable alternative employment.

The insurer was granted a credit for W.C.B. benefits the applicant received.

The applicant, a professional folk singer, was injured in a motor vehicle accident and received weekly income benefits for 156 weeks.

The insurer terminated benefits, arguing he was capable of returning to work.

The arbitrator found that the applicant suffered from severe post-traumatic depression, largely stemming from his genuine belief that he could no longer sing professionally due to dental and facial injuries.

Applying section 12(5)(b) of the Statutory Accident Benefits Schedule, the arbitrator concluded the applicant was continuously prevented from engaging in any occupation for which he was reasonably suited by education, training, or experience.

Ongoing weekly income benefits, interest, and expenses were awarded.

The applicant sought weekly income benefits following a motor vehicle accident.

The insurer terminated benefits after approximately two and a half years, arguing her ongoing physical complaints were due to a pre-existing condition rather than the accident.

The arbitrator found the applicant lacked credibility, noting she deliberately misrepresented her extensive pre-accident medical history and the severity of her initial injuries to various medical practitioners.

Relying on the insurer's physiatrist, the arbitrator concluded the applicant's pain magnification was conscious and deliberate, and that she failed to establish a causal connection between the minor accident and her alleged disability.

The application for benefits and expenses was dismissed.

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

The applicant applied for arbitration, claiming ongoing weekly income benefits on the basis that severe, unpredictable headaches caused by the accident continuously prevented him from engaging in any occupation for which he was reasonably suited.

The Arbitrator found the applicant credible and accepted medical evidence that his severe headaches were debilitating and unpredictable.

The Arbitrator concluded that the applicant was continuously prevented from engaging in suitable employment and ordered the insurer to pay ongoing weekly income benefits and arbitration expenses.

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

After working for over a year, he left his employment due to chronic pain and substance abuse, and sought reinstatement of his benefits.

The arbitrator held that returning to work for more than 90 days under section 16(2) of the Schedule merely shifts the onus to the insured to re-establish disability, rather than acting as a complete bar.

The arbitrator also interpreted the 156-week period in section 12(5)(b) as 156 weeks of disability, not consecutive weeks from the accident.

Finding that the applicant's poor psychological health and substance abuse rendered him disabled, the arbitrator awarded weekly income benefits for the claimed period.

The applicant was injured in a motor vehicle accident and received weekly income benefits from the insurer until they were terminated on the basis that he no longer suffered a substantial inability to perform the essential tasks of his employment.

The applicant, who was self-employed as a grocery store owner, sought ongoing weekly income benefits and the cost of occupational retraining.

The arbitrator found that the applicant remained substantially unable to perform his essential tasks until he completed a physical reconditioning program, extending his entitlement to benefits.

The arbitrator also determined the quantum of benefits by applying an 'avoidable expenses' approach to calculate the applicant's pre-accident gross weekly income.

The claim for occupational retraining was dismissed as the applicant was found capable of returning to his pre-accident occupation with reasonable modifications.