Leilah Edroos

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

The insurer stopped the benefits and sent multiple Explanation of Benefits (OCF-9) forms.

The insurer argued the applicant's claim for arbitration was statute-barred as it was commenced more than two years after the refusal.

The arbitrator found that the insurer's refusal was not clear and unequivocal, as it emphasized the rebuttal process without adequately informing the applicant of other dispute resolution steps like mediation and arbitration.

Therefore, the limitation period was not triggered, and the applicant's claim was not statute-barred.

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

After disputes arose, she applied for arbitration but subsequently failed to communicate with her legal representatives or participate in the proceedings.

Her representatives were permitted to withdraw.

The insurer brought a motion to dismiss the application under Rule 68 of the Dispute Resolution Practice Code.

The arbitrator found that the applicant's failure to participate rendered the proceeding frivolous or vexatious and dismissed the application.

The applicant sought statutory accident benefits following a motor vehicle accident, including a determination of catastrophic impairment, non-earner benefits, attendant care, housekeeping, and medical benefits.

The arbitrator found that the applicant failed to prove catastrophic impairment, noting evidence of sub-maximal effort and malingering on psychological tests, and surveillance contradicting physical impairment claims.

The claim for non-earner benefits was dismissed because the applicant was already completely unable to carry on a normal life prior to the accident due to a pre-existing major depressive disorder.

However, the arbitrator awarded attendant care, housekeeping, and certain medical benefits for the first 12 months post-accident, finding them reasonable and necessary for that limited period.

Claims for a special award were dismissed.

The defendant insurer brought a motion seeking two defence medical examinations by an orthopedic specialist and an occupational therapist and production of the clinical notes and records underlying two expert reports recently served by the plaintiff.

The action arose from a 1994 motor vehicle accident and a dispute over termination of statutory accident benefits.

The court held that the defendant had previously obtained numerous medical assessments and had set the matter down for trial, indicating readiness to proceed on the existing evidence.

In the absence of evidence demonstrating a substantial and unexpected change in circumstances, the defendant failed to meet the threshold required to reopen interlocutory steps.

The request for production of underlying clinical notes and records was also rejected.

The applicant sought to withdraw her application for arbitration regarding statutory accident benefits.

The insurer opposed a complete dismissal, seeking to maintain its claims for repayment of benefits and expenses based on allegations of fraud and misrepresentation.

The arbitrator allowed the applicant to withdraw her issues but held that under section 282(3) of the Insurance Act, the arbitration must continue to determine the issues raised by the insurer.

The insurer was given 30 days to advise if it wished to proceed with its claims.

The insurer brought a motion seeking an order to compel the insured person to attend psychiatry, physiatry, and neurology assessments, and to adjourn the ongoing arbitration hearing pending her attendance.

The insurer had not served a proper Notice of Examination under section 65 of the Statutory Accident Benefits Schedule prior to the motion.

The arbitrator dismissed the motion, finding no jurisdiction to order attendance without proper Notice.

Furthermore, the arbitrator noted that the insurer did not intend to rely on the assessment reports in the current arbitration, and that the insurer's delay in requesting the assessments was unreasonable.

The insurer appealed an arbitrator's decision denying its request for an order requiring the insured to attend insurer examinations (IEs) with a psychiatrist, oncologist, and physiatrist.

The Director's Delegate confirmed the arbitrator's decision, finding no error in the conclusion that the insurer failed to provide sufficient evidence that the IEs were reasonably necessary.

The appeal was dismissed.

The applicant was injured in a motor vehicle accident and subsequently signed a settlement agreement with the insurer for additional statutory accident benefits.

The applicant later sought to rescind the settlement, arguing the settlement documents did not comply with the Settlement Regulation.

The arbitrator held that the insurer bears the onus of proving compliance with the Settlement Regulation, rejecting the application of the presumption of regularity to private insurance settlements.

The arbitrator found that the settlement documents failed to provide the required commuted values and maximum monetary limits for various benefits, thereby failing to achieve even minimal compliance.

The applicant was therefore entitled to rescind the settlement and pursue her claim for additional benefits.