Ian A. Little

The late insured was involved in a motor vehicle accident while suffering from Stage IV metastatic lung cancer.

He died several months later.

His estate and family members applied for statutory accident benefits, including death benefits, funeral expenses, and the cost of installing a Jacuzzi, arguing that the accident-related injuries interrupted his cancer treatment and contributed to his death.

The arbitrator dismissed the claims, finding based on expert oncological evidence that the accident did not materially contribute to the progression of the cancer or the insured's death, which was inevitable due to the advanced disease.

The arbitrator also found that the stepson was not a dependant and that the Jacuzzi was neither a reasonable nor necessary medical or rehabilitation expense.

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

The insurer terminated her income replacement benefits, arguing she was capable of returning to work.

The arbitrator found that the applicant made honest and sustained attempts to return to her pre-accident employment as an accountant, but was unable to continue due to her injuries.

The arbitrator rejected the insurer's medical assessments suggesting a lack of motivation, finding the applicant's testimony credible and her attempts to work genuine.

The applicant was found to be substantially disabled from performing the essential tasks of her employment and completely unable to engage in suitable employment, entitling her to ongoing income replacement benefits.

The applicant was struck by a vehicle and claimed statutory accident benefits, including attendant care and housekeeping benefits beyond the 104-week mark.

The insurer terminated these benefits on the basis that the applicant did not suffer a catastrophic impairment.

The arbitrator reviewed the medical evidence, including a Designated Assessment Centre (DAC) assessment, and found that the applicant's whole person impairment was 30 per cent, falling short of the 55 per cent threshold required for a catastrophic impairment.

The arbitrator also found no evidence of a class 4 or 5 mental or behavioural disorder.

The claims for attendant care, housekeeping, and auto repair expenses were dismissed, and the applicant was ordered to pay the insurer's arbitration expenses.

The applicant was injured in a motor vehicle accident and received income replacement benefits from the insurer.

The insurer terminated benefits after 104 weeks and sought repayment, alleging the applicant misrepresented his pre-accident income.

The arbitrator found the applicant was not completely disabled from working as a self-employed renovator, relying on medical evidence including the applicant's own treating surgeon.

The arbitrator also found the applicant lacked credibility and had falsified his tax returns to inflate his business expenses and hide income.

Consequently, the applicant failed to prove the quantum of his income replacement benefit.

The arbitrator ordered the applicant to repay $33,997.72 to the insurer due to wilful misrepresentation and ordered him to pay the insurer's arbitration expenses.

The applicant claimed she was injured in a bus rollover accident in New York and sought income replacement benefits, medical expenses, and clothing expenses from her insurer.

The insurer denied the benefits.

At arbitration, the arbitrator found that while an accident likely occurred, the medical evidence did not establish that the applicant suffered a substantial inability to perform the essential tasks of her pre-accident employment as a chambermaid.

Claims for taxi, motel, and clothing expenses were also dismissed for lack of evidence.

The insurer's late argument that the applicant was disentitled for failing to provide information was rejected.

The insurer was ordered to pay 70% of the applicant's arbitration expenses due to the applicant advancing legitimate claims, reduced because of late production of her arbitration brief.

The applicant was injured in a motor vehicle accident and received income replacement benefits until the insurer terminated them based on an orthopaedic assessment.

The applicant sought benefits for the period until he returned to full-time work, arguing that a combination of physical pain, sleep apnea, and psychological distress rendered him substantially unable to perform his sedentary job.

The arbitrator found the applicant credible and held that the accident materially contributed to his deteriorating physical and mental condition.

The arbitrator concluded the applicant was substantially disabled from performing the essential duties of his employment during the disputed period and ordered the insurer to pay the benefits with interest.

The applicants were injured in a motor vehicle accident and sought statutory accident benefits from their insurer.

They claimed the cost of an Obus Forme mattress and foundation to alleviate sleep disturbances caused by accident-related back pain.

The insurer denied the claim, arguing it was not a medical expense and that the applicants failed to submit a treatment plan beforehand.

The arbitrator found the mattress was a reasonable and necessary medical expense, materially contributing to sleep restoration, but denied the cost of the foundation due to insufficient evidence.

The arbitrator also awarded interest on the mattress cost and on previously overdue income replacement benefits, but clarified that interest does not compound on overdue interest once the principal benefit is paid.

The applicants were awarded their arbitration expenses.

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

The applicant sought arbitration for ongoing weekly income benefits, housekeeping, babysitting, and occupational training expenses.

The arbitrator found the applicant was entitled to weekly income benefits up to June 30, 1998, as she was physically capable of performing suitable full-time work by that date.

The arbitrator also awarded partial housekeeping and babysitting expenses, but denied the claim for occupational training expenses.

The insurer appealed an arbitrator's decision that an excluded driver endorsement was valid but only took effect after the first of two motor vehicle accidents.

The insureds cross-appealed, arguing the endorsement was entirely invalid.

The Director's Delegate allowed the cross-appeal, finding that the endorsement was not validly executed because the insured and the excluded driver signed in the wrong places, and the insured, who faced a language barrier, did not have the requisite intent to exclude her husband.

The insurer's appeal was dismissed.

The applicant was injured in two motor vehicle accidents in 1996 and sought statutory accident benefits for caregiver, housekeeping, and attendant care expenses.

The insurer terminated caregiver benefits and denied attendant care, alleging the applicant was malingering and exaggerating her symptoms, pointing to a pre-existing slip-and-fall injury and substance abuse issues.

The arbitrator found that the applicant sustained psychological and physical injuries in the accidents, leading to disabling psychological and chronic pain conditions.

The arbitrator rejected the insurer's malingering argument, finding the applicant's substance abuse was a misguided effort to control pain.

The applicant was awarded caregiver benefits from February 4, 1997, and attendant care benefits for a limited period, but her claim for additional housekeeping benefits was denied.

The applicants were injured in two motor vehicle accidents in 1995.

The insurer argued that an excluded driver endorsement signed by the applicants barred the husband from receiving further statutory accident benefits, as he was driving the wife's vehicle at the time of both accidents.

The arbitrator found that the endorsement was valid and understood by the husband, but the insurer could only rely on it for the second accident because it had not received the signed endorsement prior to the first accident.

The endorsement barred the husband's claim for income replacement benefits for the second accident, but had no effect on the wife's claims for benefits.

Following an arbitration decision regarding statutory accident benefits where the applicant had mixed success, the parties sought a determination on expenses.

The insurer argued the applicant should only receive half his expenses because he was unsuccessful on the income replacement benefit claim.

The arbitrator awarded full expenses to the applicant, finding that the insurer's procedurally defective adjustment of the medical and rehabilitation claims justified a full award despite the applicant's lack of complete success.

The applicants, who were injured in a motor vehicle accident, sought an interim award for the payment of physiotherapy expenses and a special award against the insurer for unreasonably withholding payment.

The insurer argued that the applicants had not provided a 'Certificate of Reasonableness' or established that they suffered an impairment as a result of the accident.

The arbitrator dismissed the motion, finding that the applicants failed to establish a prima facie case for entitlement to the benefits and did not demonstrate sufficient urgency to justify an interim order.

The request for a special award was also dismissed as inappropriate on an interim basis.

The applicant was injured in a motor vehicle accident and received income replacement benefits until returning to heavy physical work.

Ten months later, he stopped working due to back pain and sought reinstatement of benefits, claiming the disability resulted from the accident.

The insurer denied the claim, arguing the new disability was a work-related repetitive strain injury.

The arbitrator agreed with the insurer on causation, dismissing the claim for income replacement benefits.

However, because the insurer unilaterally terminated payment for medical and rehabilitation treatments without following the mandatory dispute resolution procedures under the Statutory Accident Benefits Schedule, the arbitrator ordered the insurer to pay for those treatments up to the date it formally notified the providers of the negative assessment results, plus a 25% special award for unreasonable withholding.

The applicant was injured in a motor vehicle accident when struck as a pedestrian.

She applied for statutory accident benefits, including caregiver benefits, housekeeping expenses, and various medical and rehabilitation expenses.

The insurer terminated weekly income replacement benefits and denied several medical expenses.

The arbitrator found that the applicant had significant pre-existing medical conditions and exaggerated her symptoms, concluding she was capable of performing her pre-accident activities by October 1996.

Claims for ongoing caregiver and housekeeping benefits beyond that date were dismissed.

However, the arbitrator allowed claims for indexation, limited housekeeping expenses prior to October 1996, and certain psychological, massage, and acupuncture treatments deemed reasonable and necessary.

The claim for a special award was dismissed.

The applicant sought statutory accident benefits following a single-vehicle accident.

The insurer disputed the claim, alleging the applicant was not a passenger in the vehicle at the time of the accident, relying on a police report that listed a different individual and a polygraph examination suggesting the applicant was deceptive.

The arbitrator found the polygraph evidence to be of no weight due to a lack of evidence regarding its reliability.

Concluding that the insurer's theory of a complex fraud was highly unlikely, the arbitrator held on a balance of probabilities that the applicant was indeed a passenger in the vehicle and awarded expenses to the applicant.

The applicants, a mother and son, sought statutory accident benefits following separate motor vehicle accidents.

The mother claimed ongoing caregiver benefits, housekeeping expenses, and medical benefits, including a Kenko mattress system.

The son claimed caregiver benefits, education disability benefits, and physiotherapy expenses.

The arbitrator dismissed all claims, finding both applicants lacked credibility.

The mother's evidence regarding her inability to perform caregiving and housekeeping duties was contradicted by objective medical assessments and home assessments.

The son's claim that he was the primary caregiver for his sisters was found to be frivolous and fabricated.

The arbitrator awarded the insurer one-fourth of its expenses in respect of the arbitration due to the son's application being frivolous and made in bad faith.

The appellant was injured in a motor vehicle accident and claimed caregiver benefits under the Statutory Accident Benefits Schedule.

The insurer paid a lower rate of disability benefits and later terminated them after an independent medical examination.

The appellant requested a Designated Assessment Centre (DAC) evaluation, which also concluded she was not disabled.

At arbitration, the arbitrator found the appellant was entitled to the higher caregiver benefit rate but only until the date of the first medical examination.

On appeal, the appellant argued that section 64 of the SABS required the insurer to pay benefits until the DAC report was issued.

The Director's Delegate dismissed the appeal, holding that section 64 governs the process for stopping benefits but does not create an absolute entitlement immune from a later finding that disability ended earlier.

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

The insurer refused to pay, and the applicant applied for arbitration.

The insurer raised preliminary issues regarding whether the applicant was precluded from arbitration for failing to submit a completed application for benefits (s. 59) and failing to attend insurer's examinations (s. 65).

The arbitrator found that the applicant substantially complied with the application requirement but failed to make himself reasonably available for the scheduled medical examinations without a reasonable explanation.

As a result, the applicant was precluded from commencing an arbitration proceeding.

The applicant was injured in a motor vehicle accident and received income replacement benefits, which were later terminated.

In a previous decision, the arbitrator found the applicant entitled to benefits for a specific period.

The issue in this hearing was the quantum of those benefits, specifically whether sick leave benefits received by the applicant should be deducted.

The arbitrator held that under section 75(2)(b) of the Statutory Accident Benefits Schedule, only 'available' but unreceived sick leave benefits are exempt from deduction.

Since the applicant had actually received the sick leave benefits, they were properly deducted, resulting in an award of $376.76 per week.