Thomas R. Hughes

The applicant sought statutory accident benefits after slipping and falling in a parking lot shortly after retrieving items from the trunk of their vehicle.

The respondent insurer denied the claim, arguing the incident did not meet the definition of an 'accident' under the Statutory Accident Benefits Schedule.

The Licence Appeal Tribunal applied the purpose and direct cause tests, finding that the applicant's use of the vehicle had ended when the trunk was closed and the fall occurred during a new task of walking away.

The application was dismissed.

The respondent insurer requested a reconsideration of a Licence Appeal Tribunal decision that awarded the applicant the cost of an orthopaedic assessment.

The Tribunal originally found that the insurer failed to provide a 'clear and unequivocal' denial of the treatment plan and that the insurer requested an insurer's examination more often than reasonably necessary.

On reconsideration, the Vice-Chair held that the Tribunal made significant errors of law and fact, noting that section 38(8) of the Schedule does not require a 'clear and unequivocal' denial and that the insurer's notice was compliant.

The Vice-Chair also found a breach of procedural fairness because the insurer was not given an opportunity to make submissions on the frequency of examinations.

Upon reviewing the merits, the Vice-Chair concluded the applicant failed to prove the orthopaedic assessment was reasonable and necessary, and varied the decision to dismiss the application for the assessment.

The insurer requested a reconsideration of a Licence Appeal Tribunal decision that denied its claim for repayment of non-earner benefits paid in error to the respondent.

The original decision found that the 12-month limitation period under section 52(3) of the Statutory Accident Benefits Schedule began to run from the date of the first payment.

On reconsideration, the Vice-Chair found this interpretation to be a significant error of law.

The Vice-Chair held that section 52(3) unambiguously allows an insurer to seek repayment of benefits paid in error within the 12 months preceding the notice.

The reconsideration request was granted, and the respondent was ordered to repay $2,193.57.

The insurer's request for costs was denied.

The applicant sought reconsideration of a decision denying her claim for accident benefits after she slipped and fell at a gas station.

The adjudicator had previously found that the incident did not meet the definition of an 'accident' under the Statutory Accident Benefits Schedule.

On reconsideration, the applicant argued that the adjudicator erred in applying the two-part test for an accident.

The adjudicator dismissed the request, finding no error of law or fact in the application of the purpose and causation tests, as the applicant had completed refuelling and was walking away from her vehicle when she fell.

The applicant sought statutory accident benefits after slipping and falling at a gas station after refuelling her vehicle.

The respondent denied the claim on the basis that the incident was not an 'accident' under section 3(1) of the Statutory Accident Benefits Schedule.

The Licence Appeal Tribunal held a preliminary issue hearing to determine if the incident met the definition of an accident.

The Tribunal applied the two-part purpose and causation test and found that the applicant was walking away from her car when she fell, meaning the ordinary use of the vehicle had ended.

Furthermore, the fall was an intervening act and the direct cause of her injuries, not the use or operation of the vehicle.

The Tribunal also dismissed the applicant's motion to compel and exclude evidence.

The application was dismissed.

The applicant insurer sought repayment of $2,193.57 in non-earner benefits paid to the respondent, arguing it had mistakenly applied a 4-week waiting period instead of the applicable 26-week waiting period.

The respondent argued the insurer's notice of repayment was out of time under s. 52(3) of the Statutory Accident Benefits Schedule, as it was sent more than 12 months after the first erroneous payment.

The Tribunal agreed with the respondent, finding that the 12-month limitation period commences from the first payment made in error, rejecting the insurer's argument for a 'rolling limitation period.' The application for repayment was dismissed, and the respondent's request for costs was also denied.

The respondent insurer sought reconsideration of a case conference order denying its request for the production of photographs taken by the applicant after a slip and fall incident.

The insurer argued the adjudicator erred by refusing to order production of a relevant document.

The Vice-Chair denied the reconsideration request, finding that the insurer failed to demonstrate how the photographs were relevant or material to determining whether the incident constituted an accident under the Statutory Accident Benefits Schedule.

The applicant sought payment for a psychological assessment, interest, and a special award following a motor vehicle accident.

The Licence Appeal Tribunal dismissed the claims, finding the applicant failed to provide a detailed breakdown of the assessment costs to prove they were reasonable and necessary.

The Tribunal also found the assessment report lacked cogent analysis to support its diagnoses.

Consequently, claims for interest and a special award for unreasonable delay were also dismissed.

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

After an arbitrator dismissed her claims for various treatment and assessment costs, she appealed.

The Director's Delegate allowed the appeal in part, finding the arbitrator erred in law by failing to award the costs of preparing treatment plans that the insurer had actually approved.

The Delegate also found the arbitrator erred in law by focusing on the reasonableness of a follow-up in-home assessment when the insurer had failed to respond to the application, and by making unsupported factual inferences that the assessment never took place.

The issue of whether the assessment expenses were actually incurred was remitted to a new arbitrator.

The Appellant appealed an arbitration decision denying her claims for statutory accident benefits.

At the oral appeal hearing, the Appellant raised a new ground of appeal based on section 38.2 of the 1996 Schedule, which had not been previously raised or briefed.

To ensure fairness and avoid litigation by stealth, the Director's Delegate adjourned the hearing to allow for written submissions on whether the new ground should be permitted and its substance.

The Appellant was ordered to pay the Respondent $750 in costs thrown away for the adjourned hearing.

The appellant insurer appealed an arbitrator’s decision that snow plow vehicles involved in a motor vehicle accident were “commercial vehicles” under Ontario Regulation 664 and therefore subject to the statutory loss transfer regime under the Insurance Act.

The appellant argued the definition required that a vehicle first be used primarily to transport goods, tools, or equipment before falling within the enumerated list following the phrase “and includes.” The court held that the enumerated list broadens the definition and captures vehicles such as those designed for construction or maintenance purposes even if they are not primarily used for transporting materials.

Applying a contextual and purposive approach to statutory interpretation, the court found the arbitrator correctly interpreted the regulation.

The appeal was dismissed and the arbitrator’s conclusion that the snow plows were heavy commercial vehicles subject to loss transfer was upheld.

The appellant insurer sought leave to appeal a preliminary arbitration decision, which was rejected by the Director's Delegate.

The respondent insured subsequently sought his legal expenses for successfully resisting the leave application.

The Delegate found that the respondent was entirely successful and that the appeal had delayed the resolution of substantive issues.

The Delegate awarded the respondent his legal expenses, finding the claimed hourly rates and time spent to be reasonable, and fixed the costs at $4,317.64 inclusive of HST.

The insurer sought to appeal an arbitrator's preliminary decision which held that the insurer had waived its right to dispute whether the claimant's incident met the definition of an 'accident' under the Statutory Accident Benefits Schedule.

The Director's Delegate considered the criteria for hearing an appeal of a preliminary order under Rule 50.2 of the Dispute Resolution Practice Code.

Finding that hearing the appeal at this stage would not provide the quickest, most just, and least expensive resolution of the dispute, the Delegate rejected the appeal without prejudice to the insurer's right to renew it upon the issuance of a final arbitration decision.