Lee Samis

The minor applicants' mother was killed in a motor vehicle accident.

Her common law spouse received workers' compensation survivor benefits.

The applicants claimed death benefits under section 11(2) of the Statutory Accident Benefits Schedule.

The insurer denied the claim, arguing that section 20 of the Schedule precluded payment because workers' compensation benefits were payable in respect of the deceased.

The arbitrator held that section 20 is an exclusionary clause that must be interpreted narrowly.

Because the deceased herself was not entitled to receive the workers' compensation benefits, section 20 did not apply to exclude the dependants' claims.

The applicants were found entitled to the death benefits.

In a supplementary decision, the Arbitrator calculated the exact amount of weekly income benefits owing to the applicant following a motor vehicle accident.

The parties agreed on the base figures but disputed the calculation of the applicant's average gross weekly income from her business.

The Arbitrator determined the net business income for the 52 weeks preceding the accident, calculated the gross weekly income, and applied the statutory formula.

After deducting amounts paid by the insurer and post-accident earnings, the insurer was ordered to pay $27,460.78 plus interest.

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

The parties disputed the calculation of her weekly income benefit.

The arbitrator determined that vacation pay should be included in the calculation of gross weekly income, but severance pay received pursuant to the Employment Standards Act should not be included, as it is not a payment for loss of income.

The applicant's weekly income benefit was set at $207.63.

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

The insurer terminated weekly income benefits, and the applicant sought arbitration for ongoing income benefits, chiropractic expenses, and transportation expenses.

The arbitrator found that the applicant, who had a pre-existing back condition, was capable of returning to his modified duties as a mail service courier by October 1993.

The arbitrator also concluded that ongoing daily chiropractic treatments two and a half years post-accident were no longer reasonable or necessary.

The applicant's claims for ongoing benefits were dismissed, and he was ordered to repay 14 weeks of income benefits to the insurer, as he had received overlapping disability benefits from another source.

The applicant was awarded the expenses of the arbitration.

The Applicant was injured in a motor vehicle accident and claimed expenses for a Health Care Aide to assist her at home, arguing these were 'nursing services' under section 6(1)(a) of the Statutory Accident Benefits Schedule, which has no monthly limit.

The Insurer argued the services were 'care' benefits under section 7, subject to a $3,000 monthly limit.

The Arbitrator held that the services provided by the Health Care Aide were best described as 'care' rather than 'nursing services,' as they were primarily focused on assisting with daily tasks rather than active treatment or rehabilitation.

Therefore, the benefits were limited to $3,000 per month under section 7.

The applicant was injured in a motor vehicle accident and received statutory accident benefits until the insurer terminated them, claiming she no longer met the eligibility test.

The applicant sought arbitration for ongoing weekly benefits and supplementary medical and rehabilitation benefits for chiropractic care.

The arbitrator found that while the applicant continued to experience discomfort and a minor disability, she had not established a substantial inability to perform her essential tasks.

The arbitrator also concluded that prolonged, open-ended chiropractic treatments were not reasonable or necessary.

The claims for ongoing benefits were dismissed, but the applicant was awarded her arbitration expenses as the application was not frivolous.

The Applicant was injured in a motor vehicle accident and sought weekly income benefits.

He was the president and controlling shareholder of an electrical contracting business.

The Insurer argued the Applicant should be treated as self-employed, attributing the company's income and expenses directly to him, which would reduce his benefits.

The arbitrator rejected the Insurer's approach, finding that the Applicant's pre-accident salary of $600 per week was a real and reasonable salary within the context of the company's history.

The arbitrator ordered the Insurer to pay the maximum weekly income benefit of $600, without deducting business expenses or post-accident corporate income, plus interest and arbitration expenses.

The applicant, a taxi driver, was injured in a motor vehicle accident while driving a cab owned by another individual and insured by Canadian General.

She also owned a personal vehicle insured by Pilot.

Canadian General argued that she was not a named insured under its policy and must claim benefits from Pilot.

The arbitrator found that the cab was made available for the applicant's regular use and rented to her, bringing her within subsection 3(1) of the No-Fault Benefits Schedule.

This provision gave her the same rights as a named insured, allowing her to elect to claim benefits from Canadian General under subsection 268(5) of the Insurance Act.

Canadian General was held liable to pay the benefits.

The applicant was injured in a motor vehicle accident and received no-fault benefits until they were terminated by the insurer.

The parties attended mediation, and the mediator issued a report stating the issues were settled.

The applicant disputed the settlement and applied for arbitration.

The insurer raised a preliminary objection, arguing the matter was settled.

The arbitrator held that an arbitrator has jurisdiction under the Insurance Act to determine whether a binding settlement was reached.

The arbitrator found that no binding agreement existed due to a misunderstanding between the parties, despite the applicant having cashed the settlement cheques.

The applicant was permitted to proceed to arbitration but was ordered to repay the settlement funds mistakenly paid by the insurer.

The Applicant was injured in a motor vehicle accident and received statutory accident benefits until the Insurer terminated them.

The parties attended mediation, and the mediator issued a report stating the issues were settled.

The Applicant disputed the settlement and applied for arbitration.

The Insurer raised a preliminary objection, arguing the matter could not proceed to arbitration because mediation had not failed.

The Applicant sought to introduce evidence of discussions held during mediation to prove no settlement was reached.

The arbitrator held that while the mediator's report is not conclusive, evidence of statements made during mediation is privileged and inadmissible without the consent of the Commissioner.

The Applicant was injured in a motor vehicle accident and received no-fault benefits until the Insurer terminated them after he twice failed to attend an independent medical examination.

The Applicant applied for mediation and then arbitration.

The Insurer brought a preliminary motion arguing the arbitrator lacked jurisdiction because the Applicant failed to make himself reasonably available for the medical examination, which is a prerequisite for mediation under section 25 of the No-Fault Benefits Schedule.

The arbitrator found that the Applicant did not have a reasonable excuse for missing the appointments and was therefore barred from mediation and arbitration.

The Insurer's motion was granted, the application was dismissed for lack of jurisdiction, and the Insurer was entitled to a refund of its arbitration assessment fee.

The applicant was seriously injured in a motor vehicle accident in which her husband was killed.

She claimed care benefits under the No-Fault Benefits Schedule for the gross income lost by her son, who took time off work to visit and care for her in the hospital.

The arbitrator found that the son's attendance to provide reassurance, support, and translation services constituted 'caring for the insured person' under s. 7(1)(a).

The arbitrator awarded $2,030.34 for the income reasonably lost by the son during the first month, but denied the claim for the subsequent period.

The applicant's claim for a special award for unreasonably withheld payments was dismissed.

The applicant, a self-employed duct cleaner, was injured in a motor vehicle accident and received weekly income benefits until they were terminated by the insurer.

The applicant sought reinstatement of benefits for the period from May 10, 1991, to September 30, 1991, arguing he was substantially unable to perform the physical tasks of his employment.

The insurer relied on surveillance evidence and an independent medical examination suggesting the applicant could return to work.

The arbitrator found the applicant credible, noting his essential tasks were physically demanding, and concluded the medical evidence supported his inability to work during the disputed period.

The applicant was awarded the claimed benefits, interest, and expenses.

The Appellant, an injured worker entitled to workers' compensation benefits, appealed an Arbitrator's decision denying him no-fault benefits under section 21 of the No-Fault Benefits Schedule.

The Appellant argued that the plain wording of section 21 entitled him to benefits either because he commenced a tort action or because he was not receiving workers' compensation payments.

The Director's Delegate upheld the Arbitrator's interpretation that section 21 requires a bona fide action for threshold-type injuries, and found the Arbitrator had jurisdiction to determine the action was not bona fide as it was commenced solely to qualify for no-fault benefits.

The appeal was dismissed, but the Appellant was awarded expenses due to the novelty and importance of the legal issues.

The applicant was injured in a motor vehicle accident and received weekly income benefits until the insurer terminated them, arguing she was no longer disabled.

The applicant, a real estate agent, claimed she could not work the long and unpredictable hours required by her occupation due to ongoing neck and back pain.

The arbitrator preferred the medical evidence of the applicant's treating specialist over the insurer's expert, finding that the ability to perform essential tasks must incorporate the ability to perform them in a manner that renders the work remunerative.

The arbitrator concluded the applicant suffered a substantial inability to perform the essential tasks of her occupation and ordered the reinstatement of weekly income benefits.