Roland Spiegel

The appellant appealed an arbitration order dismissing her claim for the cost of a medical assessment under section 57(1) of the Statutory Accident Benefits Schedule.

The assessment was arranged by her former counsel two years after the insurer stopped funding her treatment, and there was no evidence that the resulting report was used to advance a claim for benefits or that the recommended treatment was pursued.

The Director's Delegate upheld the arbitrator's finding that the appellant failed to prove the assessment was reasonably incurred for the purposes of the Regulation.

The appeal was dismissed with expenses awarded to the insurer.

The appellant was injured in a motor vehicle accident and sought payment for a multidisciplinary assessment under s. 24 of the SABS-1996.

The arbitrator allowed the costs for the physiotherapy and functional abilities assessments but denied the cost of the orthopaedic assessment.

Both parties appealed.

The Director's Delegate dismissed the appeal and cross-appeal, finding that the arbitrator correctly applied a flexible, contemporaneous reasonableness test to determine whether the assessments were obtained for the purpose of the regulation.

The Delegate also declined to admit fresh evidence on appeal and dismissed a motion alleging institutional bias.

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

At the arbitration hearing, the applicant's representative brought preliminary motions alleging institutional bias against FSCO, requesting an adjournment pending an appeal in another case, and seeking the appointment of a private arbitrator.

The arbitrator dismissed the preliminary motions, finding no evidence of bias and no authority to appoint a private arbitrator.

The applicant's representative then alleged personal bias against the arbitrator and refused to proceed with the hearing on the merits.

The arbitrator dismissed the substantive claims for want of evidence and ordered the applicant to pay $1,000 towards the insurer's expenses and assessment fee due to the representative's disruptive and unfounded conduct.

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

The insurer denied certain treatment plans and requested the applicant attend insurer's examinations and a Designated Assessment Centre (DAC).

The applicant failed to return the required OCF-14/59 forms for the DAC and did not attend the insurer's examinations.

On a preliminary issue, the arbitrator held that the insurer's notice for the examinations was defective for failing to specify the benefits to which they related, meaning the applicant was not barred from arbitrating other issues.

However, the applicant's failure to return the DAC forms constituted a failure to make himself reasonably available for an assessment, barring him from arbitrating the specific treatment plans related to those DACs.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for treatment plans from a rehabilitation centre.

The insurer denied several treatment plans, relying on physiotherapy utilization guidelines rather than medical opinions, and delayed payments for initial treatments.

The arbitrator found the insurer unreasonably withheld and delayed payments, ordering payment of $1,285 for treatment and a special award of $1,223.63.

However, because the applicant flagrantly refused to comply with a pre-hearing order to produce pre-accident health records, the arbitrator denied the applicant's claim for arbitration expenses.

The applicant was injured in a motor vehicle accident and sought payment for in-home physiotherapy expenses and a special award for unreasonable withholding of benefits.

The arbitrator found that the in-home physiotherapy was reasonable and necessary, but the fees charged were not reasonable.

The arbitrator awarded $3,847.50 based on the Physiotherapists Fees Guideline.

The claim for a special award was dismissed as the insurer's refusal to pay was based on conflicting medical opinions and was not unreasonable.

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

The insurer denied benefits, initially disputing that the applicant was in the insured vehicle.

The arbitrator found the applicant was a passenger but concluded his injuries were minor soft tissue strains.

Claims for extensive physiotherapy and chiropractic treatments were partially allowed, limited to what was reasonable for an uncomplicated injury.

Claims for income replacement and other disability benefits were dismissed, as the applicant was unemployed prior to the accident and his inability to carry on a normal life was attributable to a pre-existing, chronic psychosis rather than the accident.