Gregory Van Berkel

The applicant sought $7,776.00 for hearing aids following a 2017 motor vehicle accident.

The insurer denied the treatment plan because it was submitted beyond the 260-week limit for medical benefits under section 20(1)(a) of the Statutory Accident Benefits Schedule.

Although the adjudicator found the treatment plan reasonable, necessary, and the result absurd, the Tribunal held it had no authority to set aside the strict 260-week legislative limit.

The application for benefits and interest was dismissed.

The applicant, a five-year-old pedestrian, was struck by a vehicle and sustained severe injuries, including a Glasgow Coma Scale (GCS) score of 9 recorded by paramedics shortly after the accident.

The insurer argued the low GCS score was caused by hemodynamic instability due to blood loss rather than a brain impairment.

The arbitrator found that the applicant suffered a brain impairment as a result of the accident, as the massive blood loss deprived the brain of oxygen, impairing its function and resulting in the GCS score of 9.

The arbitrator concluded the applicant met the definition of catastrophic impairment under subsection 2(1.1)(e)(i) of the Statutory Accident Benefits Schedule.

The applicant claimed statutory accident benefits following an alleged motor vehicle accident.

Neither the applicant nor her representative attended the scheduled arbitration hearing.

The arbitrator proceeded in their absence and dismissed the applicant's claims for income replacement benefits, interest, and a special award due to a lack of evidence.

The insurer was awarded its expenses of the arbitration.

However, the insurer's claim for an award in respect of its assessment fee under the repealed section 282(11.2) of the Insurance Act was dismissed, as the arbitrator found the new legislative provision to be procedural and applicable retroactively.

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

The insurer denied the claim and argued at a preliminary issue hearing that the applicant was disentitled to benefits under section 48(1) of the Statutory Accident Benefits Schedule because he wilfully misrepresented the circumstances of the accident.

The insurer relied on an accident reconstruction expert who concluded the vehicle damage was inconsistent with the applicant's statements.

The arbitrator found the expert's analysis contained numerous weaknesses, including reliance on an unreliable speed estimate and photographs taken after a subsequent accident.

The arbitrator concluded the insurer failed to discharge its onus of proving wilful misrepresentation and held the applicant was not disentitled to benefits.

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

The insurer denied benefits and raised the preliminary issue of wilful misrepresentation.

The applicant objected to the late service of the insurer's expert reports and argued the insurer failed to provide proper notice of the reasons for denying benefits.

The arbitrator allowed the late expert reports, finding no procedural unfairness or prejudice to the applicant.

The arbitrator also held that the insurer provided sufficient notice of its wilful misrepresentation defence in its Response to the Application for Arbitration, allowing the preliminary issue hearing to proceed.

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

The insurer requested additional information beyond the Assessment of Attendant Care Needs (Form 1) to verify that the services were actually provided and expenses incurred.

The applicant argued that the Form 1 and the Schedule provided a complete code and no further information could be requested.

The arbitrator held that under section 33 of the Statutory Accident Benefits Schedule, the insurer is entitled to request reasonable information, including the identity of the service provider and the dates and approximate times of service, to satisfy itself that the attendant care services were provided and the expenses incurred before paying the benefit.

The insurer appealed an arbitrator's preliminary order dismissing its motion to stay the insured's arbitration proceeding.

The insurer had commenced a civil proceeding regarding the quantum of income replacement benefits one day before the insured filed for arbitration.

The Director's Delegate rejected the appeal, finding that the insured's right to elect arbitration should be respected, the arbitration was further advanced, and staying the arbitration would cause significant prejudice to the insured.

The arbitration was permitted to proceed.

The insurer brought a motion to stay the insured's arbitration proceeding at the Financial Services Commission of Ontario (FSCO) pending the outcome of a lawsuit it had filed in the Superior Court of Justice.

The insurer argued that its lawsuit, which sought a determination of the insured's income replacement benefit and repayment of alleged overpayments, was filed two days before the arbitration application.

The arbitrator dismissed the motion, finding that the arbitration had advanced more rapidly than the lawsuit and that a stay would frustrate the goal of avoiding multiple proceedings, as the court lacked jurisdiction to issue a special award.

The arbitrator emphasized that the Insurance Act gives the insured, not the insurer, the right to elect the forum for dispute resolution.

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

The applicant failed to attend the hearing or communicate with his counsel, the insurer, or the Commission.

The arbitrator dismissed the applicant's claims in their entirety due to a lack of evidence.

The insurer's claim for repayment of $2,447.72 in overpaid income replacement benefits was granted.

The arbitrator also ordered the applicant to pay the insurer's arbitration expenses of $1,742.00 and an additional $1,000 for abuse of process, finding that the applicant's failure to participate unnecessarily prolonged the proceedings.