G. Joseph Falconeri

The respondent insurer requested a reconsideration of a preliminary decision which found that the applicant's claims for attendant care and medical benefits were not statute-barred.

The original adjudicator had concluded that the insurer's denial notices were not 'clear and unequivocal' because they included an application for catastrophic impairment, which might confuse an unsophisticated person.

On reconsideration, the Associate Chair found that the adjudicator made a significant error of law or fact.

The Associate Chair held that the denial notices, which included standard-form disclosures of the right to appeal and the two-year limitation period, were clear and unequivocal.

Consequently, the reconsideration was granted, and the applicant's claims for the disputed benefits were dismissed as statute-barred.

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

The respondent insurer raised preliminary issues, arguing that several of the applicant's claims were statute-barred because she failed to appeal within the two-year limitation period, and that other claims were barred because she failed to submit them within the prescribed timelines.

The Tribunal found that the insurer's explanation of benefits for the attendant care and certain medical benefits did not constitute a clear and unequivocal denial, meaning the limitation period was not triggered and those claims could proceed.

However, the Tribunal found that the denial for the cost of examinations was clear and unequivocal, barring that claim.

The Tribunal also held that the applicant lacked a reasonable explanation for her late submission of transportation claims, barring those from proceeding.

The applicant, injured in a motor vehicle accident, sought production of the insurer's complete adjusting notes in her claim for statutory accident benefits.

The insurer refused to produce notes created after the date the applicant filed for mediation, claiming litigation privilege.

The arbitrator dismissed the motion, finding that litigation privilege applied to the adjusting records from the date of the mediation application, as legal action was imminent and the dominant purpose of the notes was preparation for conflict.

In a dispute over statutory accident benefits, both parties brought motions for the production of documents.

The insurer sought the applicant's employment and tax records to test the reliability of medical reports regarding work-related limitations.

The arbitrator ordered the applicant to produce employment records related to collateral medical benefits from one year pre-accident to the present.

The applicant sought the immediate production of all surveillance evidence obtained by the insurer.

The arbitrator held that surveillance information is subject to early disclosure to facilitate dispute resolution, finding that the applicant's interest in knowing the nature of the surveillance trumped the insurer's litigation privilege.

The insurer was ordered to produce existing and future surveillance information within 30 days.

The applicant was injured in a motor vehicle accident and received loss of earning capacity benefits.

The insurer reduced these benefits based on a Designated Assessment Centre report concluding the applicant could work as a part-time telemarketer.

The arbitrator found the assessment seriously flawed, as it failed to consider the applicant's chronic pain, medications, commute, and vocational characteristics.

The arbitrator determined the applicant's residual earning capacity was zero, ordered the insurer to repay the deducted amounts, and granted a special award of $6,000 due to the insurer's unreasonable reliance on the flawed report.

The applicant sustained a cervical spinal cord injury in a motor vehicle accident, resulting in quadriplegia.

He claimed entitlement to an increased maximum monthly attendant care benefit under section 47(6) of the Statutory Accident Benefits Schedule, arguing he also suffered a separate psychological injury (major depressive disorder) requiring additional care.

The arbitrator found that while the applicant did suffer a psychological injury as a result of the accident, the attendant care services required for this psychological impairment overlapped with the 24-hour care already required for his physical injuries.

Therefore, the applicant was not entitled to the higher maximum under section 47(6) and the insurer was obliged to pay the standard catastrophic maximum under section 47(5).

The appellant insurer appealed an arbitration decision finding it responsible for paying statutory accident benefits to the claimant.

The claimant was injured while a passenger in a vehicle insured by the respondent insurer.

The claimant applied for benefits from the appellant insurer on the basis that she was the spouse of its named insured.

The arbitrator found that the claimant and the named insured had cohabited in a relationship of some permanence and were therefore spouses under the Insurance Act.

On appeal, the Director's Delegate upheld the arbitrator's finding, concluding that there was sufficient evidence to support the determination of cohabitation despite the parties maintaining separate residences.

The appeal was dismissed, with a new issue regarding policy interpretation reserved for further submissions.

The Applicant was injured in a motor vehicle accident while driving a taxi in the course of his employment.

He applied for statutory accident benefits from Allstate, which insured his personal vehicle.

Allstate argued that Wellington, which insured the taxi, was responsible.

The arbitrator determined that the Applicant was an 'insured person' under the Allstate policy and not a 'named insured' under the Wellington policy.

Therefore, Allstate was held responsible for paying the Applicant's statutory accident benefits.