Jamie Robin Pollack

The appellant appealed an Arbitrator's order regarding statutory accident benefits, seeking clarification on whether a 50% special award applied to medical benefits in excess of his $100,000 policy limit.

The Director's Delegate dismissed the appeal, finding no error of law.

The Delegate held that the Arbitrator's jurisdiction to make a special award is strictly limited by the insured's statutory entitlement to benefits under the policy limits, pursuant to s. 282(10) of the Insurance Act.

The Arbitrator could not have ordered a special award on benefits to which the appellant was not entitled.

The applicant was seriously injured in a motor vehicle accident in Georgia and sought a determination that he sustained a catastrophic impairment under the Statutory Accident Benefits Schedule.

The parties' medical experts disagreed on the applicant's whole person impairment (WPI) rating, with the applicant's experts assessing it between 62% and 71%, and the insurer's experts assessing it between 48% and 51%.

The arbitrator preferred the evidence of the applicant's experts, finding that the applicant's physical and psychological impairments, when combined, exceeded the 55% threshold.

The arbitrator also found that the accident materially contributed to the applicant's impairments, including his atrial fibrillation and peripheral neuropathy, despite the insurer's arguments regarding pre-existing susceptibility.

The applicant was found to have sustained a catastrophic impairment.

The applicant sought to invalidate a Settlement Disclosure Notice (SDN) he signed in 2011, which settled his accident benefits claim for $115,000.

He argued the SDN was defective for failing to distinguish between different periods of Income Replacement Benefits and for lacking required language regarding rescission.

The arbitrator found the SDN valid, noting the applicant was represented by counsel at the time and understood the terms.

The issue of whether the applicant was time-barred from applying for mediation was deemed moot.

The applicant, who was catastrophically impaired in a 2010 motor vehicle accident, sought a rehabilitation benefit of $2,388.93 for occupational therapy.

The respondent insurer denied the benefit, arguing the treatment plan lacked measurable goals and timelines.

The Tribunal found the occupational therapy was reasonable and necessary to help reduce the effects of the applicant's physical and psychological disabilities and facilitate his reintegration into his family.

The Tribunal ordered the respondent to pay the benefit with interest, but denied the applicant's request for costs, finding the respondent's conduct during the proceeding was not unreasonable.

The applicant, who suffered catastrophic mental impairments following a 2010 motor vehicle accident, sought a rehabilitation benefit of $2,363.23 for occupational therapy services.

The respondent insurer denied the benefit, relying on an insurer's examination that found no clear rationale for continued therapy.

The Licence Appeal Tribunal found the treatment plan was reasonable and necessary to help the applicant cope with her psychological injuries and reintegrate into her family.

The Tribunal ordered the respondent to pay the benefit with interest, but denied the applicant's request for costs, finding the respondent had not acted unreasonably, frivolously, vexatiously, or in bad faith during the proceeding.

The applicant sought attendant care benefits following a motor vehicle accident, claiming 24-hour care provided by two non-professional service providers.

The insurer denied the benefits on the basis that the providers had not sustained an ongoing economic loss and that the applicant failed to comply with requests for income documentation under section 33 of the Statutory Accident Benefits Schedule.

The arbitrator found that the first provider did not sustain an ongoing economic loss and that both providers failed to provide timely income documentation as reasonably requested by the insurer.

Consequently, the claims for attendant care benefits were dismissed due to non-compliance with section 33.

The insured was injured in a motorcycle accident and failed to notify his insurer of a potential claim until years later.

The arbitrator found the insured had a reasonable explanation for the delay and could proceed to arbitration despite not filing a Report of Mediator, as mediation was deemed to have failed.

On appeal, the Director's Delegate upheld the finding of a reasonable explanation but allowed the appeal on the basis that the insured had never claimed a specific accident benefit.

Consequently, there were no issues in dispute that had failed at mediation, precluding the insured from proceeding to arbitration.

The insurer sought its legal expenses following the dismissal of the insured's appeal regarding statutory accident benefits.

The insured did not provide a written response to the Bill of Costs but disputed entitlement to a portion of the expenses at the teleconference.

The Director's Delegate found the insured's late objection unfairly surprised the insurer and declined to reduce the hours on that basis.

Conducting a global assessment of reasonable expenses, the Director's Delegate ordered the insured to pay the insurer $10,000 in legal expenses, inclusive of disbursements and HST.

The appellant was injured in a motor vehicle accident and claimed income replacement benefits (IRBs).

The insurer denied the claim on the basis that the appellant had not worked the required 26 weeks in the 52 weeks prior to the accident.

The appellant applied for mediation more than two years after the denial, arguing the denial was not clear and unequivocal because it invited further information.

The Arbitrator found the denial was clear and unequivocal, and dismissed the IRB claim as statute-barred.

On appeal, the Director's Delegate upheld the Arbitrator's decision, finding no error of law in the conclusion that the refusal was valid and not premature.

The applicant was injured in a motor vehicle accident and claimed attendant care benefits for services provided by his spouse.

The spouse was a certified Personal Support Worker (PSW) who took a leave of absence from her job to care for the applicant.

The insurer argued that the spouse was not providing services in the course of her employment and therefore had to demonstrate an economic loss.

The arbitrator held that the spouse was providing attendant care services in the course of the employment, occupation, or profession in which she would ordinarily have been engaged but for the accident, pursuant to s. 3(7)(e)(iii)(A) of the Schedule.

As a result, economic loss did not need to be demonstrated.

The applicant was injured in a motor vehicle accident and received an Income Replacement Benefit (IRB) until the respondent insurer terminated it, claiming the applicant could return to work.

The applicant sought reinstatement of the IRB, arguing he was physically and psychologically incapable of working.

The Tribunal found that while the applicant's physical injuries had healed, the accident materially worsened his pre-existing depression and caused severe post-traumatic stress disorder.

Preferring the evidence of the applicant's treating psychologists over the insurer's assessor, the Tribunal concluded the applicant suffered a complete inability to engage in any suitable employment.

The Tribunal ordered the respondent to pay the outstanding IRB amounts with interest.

The applicant was injured in a motorcycle accident while driving his uninsured motorcycle.

He later sought statutory accident benefits under his automobile policy with the respondent insurer.

The insurer raised preliminary issues arguing the applicant was precluded from arbitration because there was no Report of Mediator and because he failed to notify the insurer and submit an application within the prescribed time limits.

The Arbitrator found that the absence of a Mediator's Report did not preclude arbitration, as the 60-day period for mediation had expired.

The Arbitrator also found that the applicant had a reasonable explanation for the delay in applying for benefits, given his brain injury and reliance on an unresponsive neurologist.

The preliminary issues were resolved in favour of the applicant.

The applicant was injured in a motor vehicle accident and applied for a determination of catastrophic impairment under the Statutory Accident Benefits Schedule.

The core issue was whether his mental and behavioural impairments, specifically his cannabis dependence and adaptation difficulties, constituted a marked impairment (Class 4).

The arbitrator found the applicant's evidence lacking in credibility and preferred the insurer's expert evidence, concluding that the applicant's impairments were only moderate (Class 3) and his combined whole person impairment did not meet the 55% threshold.

The application was dismissed, and the insurer was awarded partial expenses due to the applicant's conduct prolonging the proceeding.

The applicant was injured in a motorcycle accident and sought statutory accident benefits from the insurer, claiming she suffered a catastrophic impairment due to a combination of physical injuries and severe psychological disorders (depression, PTSD, and chronic pain).

The arbitrator found that the applicant's combined physical and psychological impairments met the 55% whole person impairment threshold, qualifying her for catastrophic impairment status.

The arbitrator also found the applicant suffered a complete inability to carry on a normal life, entitling her to ongoing non-earner benefits.

Claims for a specialized hospital bed and certain rehabilitation expenses were granted, while claims for massage therapy, travel time, and a special award were denied.

Following the dismissal of the plaintiffs' action on a summary judgment motion, the successful defendant sought partial indemnity costs of $42,469.53.

The plaintiffs opposed the costs award, arguing that special circumstances justified denying costs to the defendant.

The court rejected the plaintiffs' arguments, finding no unreasonable conduct by the defendant.

The court reduced the claimed fees slightly due to some duplication of work and awarded the defendant $29,000 in fees, plus HST and $6,650 in disbursements, subject to clarification on a potential setoff claimed by the plaintiffs.

The moving insurer sought summary judgment dismissing an underinsured motorist claim arising from a Florida motor vehicle accident.

The responding insureds had settled the Florida action for US$300,000 despite the tortfeasor's US$1,000,000 policy limits, and then sought recovery under the OPCF 44R Family Protection Endorsement.

The court held that the insureds were not entitled to rely on an unsupported assertion of the tortfeasor insurer's potential insolvency where they had not conducted due diligence to determine whether the policy limits were unavailable at the time of settlement.

Applying Rule 20 and the governing underinsurance authorities, the court found no genuine issue requiring a trial and dismissed the action.

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

The insurer denied income replacement benefits (IRBs) on the basis that the applicant had not worked the required 26 weeks in the 52 weeks preceding the accident.

The applicant applied for mediation more than two years after the denial.

The arbitrator found that the insurer's denial was clear and unequivocal, triggering the two-year limitation period, and thus the applicant was precluded from proceeding to arbitration on the IRB claim.

However, the arbitrator found that the applicant was not precluded from proceeding with his claim for non-earner benefits (NEBs), as the insurer had separately denied that claim within the limitation period.

The applicants sought accident benefits following a motor vehicle accident, claiming that Ms. Hoey was driving the vehicle.

The insurer terminated benefits, alleging that Mr. Vera, whose license was suspended, was actually driving and that the applicants wilfully misrepresented this material fact.

Following a preliminary issue hearing, the arbitrator found that the preponderance of evidence, including independent witness testimony and Mr. Vera's actions at the scene, established that Mr. Vera was the driver.

The arbitrator concluded that both applicants wilfully misrepresented material facts, disentitling them to benefits, and awarded the insurer its reasonable expenses.

During a dispute over statutory accident benefits, the insurer inadvertently disclosed privileged documents to the applicant's counsel.

The applicant's counsel reviewed the documents and subsequently brought a motion to amend the claim to include a Special Award based on the privileged information.

The insurer brought a cross-motion to remove the applicant's counsel from the record.

The arbitrator granted the insurer's motion, finding that the applicant's counsel had reviewed the privileged documents in detail and attempted to use the information to the insurer's detriment.

The applicant's motion to amend the claim was denied as an abuse of process, and the applicant's counsel was removed from the record.

Three family members sought statutory accident benefits following a minor motor vehicle collision.

The arbitrator dismissed all claims for income replacement, caregiver, attendant care, housekeeping, and medical/rehabilitation benefits.

The arbitrator found the applicants were not credible, relying heavily on surveillance evidence that contradicted their reported disabilities.

Furthermore, the applicants' expert medical evidence was rejected due to altered clinical records, failure of experts to testify, and reliance on inaccurate self-reporting.

Claims for interest, a special award, and arbitration expenses were also dismissed.