Mark S. Grossman

The insurer appealed an arbitrator's preliminary order finding that the insured was not barred from proceeding to arbitration under s. 50(1)(a) of the SABS-1996.

The insurer argued the insured failed to submit an application for benefits within 30 days of receiving the forms, as required by s. 32(3).

The Director's Delegate dismissed the appeal, upholding the arbitrator's finding that the insured had provided sufficient information to allow the insurer to begin adjusting the claim within the required timeframe, despite not completing the approved forms.

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

The insurer denied benefits, alleging the applicant failed to submit an application within 30 days of receiving the forms, as required by section 32(3) of the Statutory Accident Benefits Schedule.

On a preliminary issue hearing, the arbitrator found that the applicant had provided sufficient information to the insurer within the 30-day period to allow it to commence adjusting the claim, even if not on the insurer's specific forms.

Furthermore, the insurer failed to properly inform the applicant of the consequences of non-compliance.

The applicant was permitted to proceed to arbitration.

The applicant was injured in a motor vehicle accident and applied for statutory accident benefits, including weekly benefits under section 13 of the Schedule.

The insurer denied the weekly benefits.

The arbitrator found that the applicant suffered a substantial inability to perform his essential tasks due to chronic pain resulting from the accident, entitling him to weekly benefits until May 1, 1995.

The arbitrator also held that vocational rehabilitation benefits received by the applicant were not deductible from the weekly benefits, as they were not payments for loss of income.

Finally, the applicant was awarded interest on the overdue benefits from July 24, 1993, as the insurer had received a completed application and sufficient medical information to adjust the claim.

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

The insurer refused to pay, relying on a designated assessment centre report which concluded the treatments were not reasonable and necessary.

The arbitrator found that the applicant had sustained a cervical fracture and that the chiropractic treatments provided appreciable subjective and objective improvement.

The arbitrator rejected the insurer's medical evidence, which relied on an unfounded diagnosis of depression, and ordered the insurer to pay the incurred chiropractic expenses.

The insurer appealed a preliminary arbitration decision finding that the insured's claim for caregiver benefits was not time-barred.

The central issue was whether the two-year limitation period for applying for mediation under the Insurance Act and the SABS-1994 commenced upon the insurer's initial notice of intention to terminate benefits or upon the release of the Designated Assessment Centre (DAC) report.

The Director's Delegate held that when an insured requests a DAC assessment, the insurer's 'refusal to pay' does not occur until the DAC report is released and the insurer is authorized to stop paying benefits.

Consequently, the limitation period had not expired, and the appeal was dismissed.

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

The insurer terminated her weekly caregiver benefits.

The applicant requested a Designated Assessment Centre (DAC) assessment.

The insurer argued that the two-year limitation period to apply for mediation commenced when it first gave notice of termination.

The arbitrator held that where an insured person elects a DAC assessment under section 64 of the Schedule, the limitation period under section 72 does not commence until the insurer receives the DAC report.

Therefore, the applicant's claim was not statute-barred.

The applicant was injured in an automobile accident and applied for weekly disability benefits.

Prior to the accident, she was receiving a CPP disability pension, which she continued to receive.

The insurer deducted the CPP disability pension from her weekly disability benefits, arguing they were 'temporary disability benefits' under section 75(4)1 of the Statutory Accident Benefits Schedule.

The arbitrator held that CPP disability benefits are of long and indefinite duration and do not fall within the definition of 'temporary disability benefits'.

Therefore, the insurer was not entitled to deduct the CPP disability pension from the applicant's weekly disability benefits.