Kevin H. Griffiths

The respondent insurer requested a reconsideration of a decision finding the applicant sustained a catastrophic impairment and was entitled to attendant care benefits (ACBs) for services provided by his spouse.

The insurer argued the adjudicator erred by admitting opinion evidence on causation from a treating chiropractor who was not qualified as an expert, and by awarding ACBs for care provided by a family member.

The Associate Chair denied the reconsideration, holding that the chiropractor's evidence was admissible as a 'participant expert' under Westerhof, and that the spouse, a trained personal support worker and registered practical nurse, provided the attendant care services in the course of her profession.

The adjudicator's findings that the applicant promised to pay his spouse and required overnight supervision were reasonable and did not constitute significant errors of law or fact.

The insurer requested a reconsideration of a Licence Appeal Tribunal decision that awarded the insured physiotherapy services, orthopaedic and psychiatric assessments, and a special award under s. 10 of Regulation 664.

The Executive Chair found no significant error of law in the adjudicator's determination that the treatment plans and assessments were reasonable and necessary for managing the insured's chronic pain.

However, the Executive Chair allowed the reconsideration regarding the s. 10 award, finding that the adjudicator erred by conflating the reasonableness of the treatment plans with the unreasonableness of the insurer's conduct.

The award was overturned as there was no evidence the insurer unreasonably withheld or delayed payments.

The applicant was injured in a motor vehicle accident and sought a determination of catastrophic impairment, along with attendant care benefits and various medical and rehabilitation benefits.

The Tribunal found that the applicant sustained a catastrophic impairment, preferring the evidence of the applicant's expert who assigned a 64% physical impairment rating over the respondent's expert.

The Tribunal awarded attendant care benefits of $3,704.91 per month from the date the assessment forms were submitted, but denied retroactive benefits.

The Tribunal also awarded case management services but denied other disputed treatment plans due to late submission or lack of evidence.

The applicant sought a non-earner benefit following a 2013 motor vehicle accident, claiming it exacerbated her pre-existing psychiatric issues and chronic pain.

The insurer denied the benefit, arguing her activities of daily living had not substantially changed.

The arbitrator found that the applicant's normal life had changed due to a prior 2011 accident and family conflicts, not the 2013 accident.

Despite an aggravation of her chronic pain, she continued to engage in substantially all her pre-accident activities, such as attending workshops, driving, and socializing.

The application was dismissed, and expenses were awarded to the insurer.

The applicant sought statutory accident benefits for physiotherapy services and orthopaedic and psychiatric assessments following a motor vehicle accident.

The respondent insurer denied the claims based on insurer examinations.

The adjudicator found that the physiotherapy services were reasonable and necessary for managing the applicant's chronic pain, rejecting the insurer's argument that treatment must lead to full recovery.

The adjudicator also approved the assessments, noting the insurer's assessors conducted paper reviews without reviewing key medical reports.

Finding that the insurer unreasonably withheld payments, the adjudicator ordered a special award of 50% of the disputed amounts, plus interest.

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

A dispute arose and the applicant applied for mediation.

The parties agreed to extend the mediation date beyond the 60-day statutory limit but failed to comply with the mandatory procedural steps under Rule 19.3 of the Dispute Resolution Practice Code.

The applicant filed for arbitration before the scheduled mediation date.

The arbitrator held that because the parties did not comply with the mandatory procedural steps to extend the mediation timeline, the agreement to extend was invalid.

Consequently, mediation was deemed to have failed at the expiry of the 60-day limit, which occurred before the arbitration application was filed.

The applicant was therefore entitled to commence the arbitration proceeding.

Following a preliminary issue hearing where it was determined that no motor vehicle accident had occurred, the insurer sought repayment of accident benefits paid to the applicants and its expenses for the arbitration.

The applicants did not participate in the written expense hearing.

The arbitrator ordered the applicants to repay the benefits they received, finding the claims were made under a misrepresentation.

The arbitrator also ordered the applicants to pay the insurer's reasonable expenses for the arbitration, reducing the claimed amount of $24,973.36 to $9,242.96 after finding the claimed legal fees and disbursements were excessive.

The applicant sought accident benefits following a motor vehicle accident.

After his representative was removed from the record, the applicant failed to attend multiple pre-hearings and the preliminary issue hearing, despite receiving proper notice.

The arbitrator proceeded in the applicant's absence and dismissed the application for arbitration due to the applicant's failure to provide evidence in support of his claims.

The insurer was awarded $3,102.00 in legal expenses and disbursements.

The applicants sought accident benefits following an alleged motor vehicle collision.

The insurer denied the claims, alleging the accident was staged and the applicants made material misrepresentations.

At a preliminary issue hearing, the arbitrator heard evidence from the applicants, the occupants of the other vehicle (who confessed to participating in a staged accident scheme), and accident reconstruction experts.

The arbitrator found the applicants' version of events highly improbable, noting inconsistencies between their testimony and the physical damage to the vehicles, the lack of independent witnesses, and the improbable behaviour of the passengers.

The arbitrator concluded the reported accident did not occur and dismissed the claims.

The respondent's son was struck by a car.

The respondent, who was sleeping, was awoken by another son and told of the incident.

While rushing down the stairs to help, the respondent fell and injured himself.

He claimed statutory accident benefits.

The arbitrator found he was involved in an 'accident' under s. 2(1) of the SABS.

On appeal, the Director's Delegate reversed the decision, finding that the respondent did not see, hear, or feel the impact, and his knowledge was mediated through his son.

This constituted an intervening act that broke the chain of direct causation.

The appeal was allowed.

The applicant sought statutory accident benefits after falling from his bicycle and sustaining a severe head injury.

The insurer disputed that the injuries were caused by the use or operation of an automobile.

At a preliminary issue hearing, the arbitrator heard uncontested expert evidence from a collision reconstructionist that the damage to the bicycle's front wheel could only have been caused by a motor vehicle running over it.

The arbitrator concluded on a balance of probabilities that the applicant was struck by an unidentified automobile, satisfying the definition of an accident under the Schedule.

The applicants applied for statutory accident benefits following a motor vehicle accident.

The insurer sought repayment, asserting the applicants were not involved in an accident as defined in the Schedule.

The applicants applied for arbitration but failed to attend the scheduled hearing or maintain contact with their counsel, who was permitted to withdraw from the record.

The arbitrator dismissed the applications for arbitration due to abandonment and ordered the applicants to pay the insurer's expenses.

The applicant applied for statutory accident benefits following an alleged motor vehicle accident, which the insurer denied on the basis that the accident was staged.

The applicant's representative brought a motion to withdraw due to a breakdown in the solicitor-client relationship.

The applicant failed to attend the arbitration hearing despite being properly served.

The arbitrator granted the representative's motion to withdraw and proceeded with the hearing in the applicant's absence.

As the applicant presented no evidence, the application for arbitration was dismissed, and the applicant was ordered to pay the insurer's expenses of $948.31.

The applicant applied for statutory accident benefits following an alleged motor vehicle accident, which the insurer denied on the basis that the accident was staged.

The applicant's representative brought a motion to withdraw due to a breakdown in the solicitor-client relationship.

The applicant failed to attend the arbitration hearing.

The arbitrator granted the representative's motion to withdraw, dismissed the application for arbitration due to the applicant's failure to attend and present evidence, and ordered the applicant to pay the insurer's arbitration expenses.

The applicant applied for statutory accident benefits following an alleged motor vehicle accident.

The insurer denied the benefits on the basis that the accident was staged.

The applicant's representative brought a motion to withdraw due to a breakdown in the solicitor-client relationship.

The applicant failed to attend the arbitration hearing despite being properly served with notice.

The arbitrator granted the representative's motion to withdraw and proceeded with the hearing in the applicant's absence.

As the applicant presented no evidence, the application for arbitration was dismissed, and the applicant was ordered to pay the insurer's arbitration expenses.

The applicant insurer sought judicial review of a Director's Delegate's decision finding that the respondent suffered a catastrophic impairment under s. 2(1.1)(g) of the Statutory Accident Benefits Schedule.

The Divisional Court granted the application and set aside the decision, holding that the Delegate erred in law by concluding that a marked impairment in only one of four areas of functioning was sufficient for a catastrophic impairment designation.

The Court further held that the Delegate erred by failing to exclude pain associated with physical injuries when assessing impairment due to mental or behavioural disorder, as required by the AMA Guides incorporated into the legislation.

The Ontario Trial Lawyers Association (OTLA) brought a motion for leave to intervene as a friend of the court in an application for judicial review concerning the interpretation of catastrophic impairment.

The applicant opposed the motion, arguing OTLA's interest was indirect and the case involved straightforward statutory interpretation.

The court granted the motion, finding that OTLA had expertise, could provide a broader perspective on the legislative scheme, and its participation would not prejudice the parties.

Leave to intervene was granted subject to conditions.

The insurer brought a motion to strike out the insured's claim for a special award prior to the arbitration hearing.

The insurer argued that because all income replacement benefits had been paid and none were outstanding at the time the application for arbitration was filed, a special award could not be granted under section 282(10) of the Insurance Act.

The arbitrator dismissed the motion, finding that the legislation mandates a special award where payments are unreasonably delayed, and that a literal interpretation requiring benefits to be outstanding at the time of the award would lead to an absurdity contrary to the consumer protection mandate of the accident benefits scheme.

The arbitrator concluded it was not plain and obvious that the claim for a special award would fail.

The applicant was injured in a pedestrian motor vehicle accident and sought a determination that she suffered a catastrophic impairment under the Statutory Accident Benefits Schedule.

The arbitrator found that while the applicant's combined physical and psychological impairments resulted in a 39% whole person impairment, falling short of the 55% threshold under clause (f), she did meet the criteria under clause (g).

Specifically, the arbitrator accepted the CAT DAC assessment that the applicant's pain disorder and physical limitations resulted in a Class 4 marked impairment in her activities of daily living.

The arbitrator held that a single marked impairment is sufficient to meet the definition of catastrophic impairment.

The applicant, injured in a motor vehicle accident, sought income replacement benefits and requested that the insurer disclose whether it had conducted surveillance and, if so, produce it 90 days before the hearing.

The insurer refused to disclose whether surveillance existed and offered to produce any relied-upon surveillance 60 days prior.

The arbitrator ordered the insurer to promptly disclose whether surveillance had been conducted and, if it intended to rely on any surveillance, to produce it 90 days before the hearing to allow the applicant sufficient time to respond with medical evidence without incurring undue financial burden under the Dispute Resolution Practice Code.