Michael Gillen

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

A dispute arose regarding the calculation of his pre-accident income from his self-employment at a family-owned car rental and repair business.

The applicant argued that significant personal expenses had been run through the company and should be added back to its profits, of which he claimed 100 percent.

The arbitrator determined the company's 1994 profit was $50,000, apportioned 50 percent to the applicant, and ordered that claim code 1 be used to determine his net income.

The applicant was also awarded expenses and interest on overdue benefits.

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

The insurer terminated these benefits after 121 weeks, having offered a zero loss of earning capacity (LEC) benefit which the applicant was deemed to have rejected.

The applicant sought ongoing income replacement benefits pending the resolution of the LEC dispute.

The arbitrator held that under section 23 of the Statutory Accident Benefits Schedule, the insurer is required to continue paying income replacement benefits unless and until it elects to pay an LEC benefit based on its offer and the residual earning capacity assessment.

The applicant sought statutory accident benefits following a motor vehicle accident, claiming entitlement to weekly income benefits and rehabilitation expenses.

The insurer terminated benefits and sought repayment, alleging the applicant was not employed at the time of the accident and misrepresented his condition.

The arbitrator found the applicant lacked credibility, having concealed a pre-existing work-related knee injury and a prior severe head injury from both the insurer and medical assessors.

The arbitrator concluded the applicant was not employed at the time of the accident and did not suffer an ongoing disability caused by the accident.

The applicant's claims were dismissed, and the insurer was granted repayment of the weekly income benefits paid, as they were induced by the applicant's culpable error and failed to account for deductible workers' compensation benefits.

The appellant appealed an arbitrator's decision regarding the calculation of weekly income benefits under the Statutory Accident Benefits Schedule.

The appellant argued that his income should be averaged only over the 33 weeks he actually worked in the 52 weeks preceding the accident, rather than the full 52 weeks.

He also argued that the arbitrator erred by not following a previous appellate decision, raising the issue of whether stare decisis applies to the tribunal.

The Director of Arbitrations held that appellate decisions of the Director are binding on first-instance arbitrators.

However, the Director agreed with the arbitrator's interpretation of the Schedule, finding that the gross weekly income must be averaged over the full 52 weeks, regardless of periods of unemployment.

The appeal was dismissed.

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

Following a pre-hearing discussion, the lawyers for the parties negotiated a settlement.

The Insurer sent a release and disclosure notice to the Applicant's lawyer, but the Applicant never signed the release.

The Insurer argued a binding settlement was reached.

The Arbitrator held that under the Settlement Regulation, a binding settlement requires the insured to confirm acceptance after receiving the mandatory disclosure notice.

Since the Applicant did not sign the release or otherwise confirm acceptance, and later communicated her rejection, no binding settlement was entered into.

The Applicant was permitted to proceed to arbitration.

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

The insurer terminated the benefits based on a medical report, providing notice to the applicant.

The applicant sought an interim order reinstating the benefits, arguing the insurer failed to comply with the technical requirements of section 64 of the Statutory Accident Benefits Schedule and failed to provide adequate reasons.

The arbitrator found that the insurer substantially complied with the notice requirements and provided adequate reasons for the termination.

The request for an interim order was dismissed.

The applicant sought statutory accident benefits after allegedly slipping and falling while exiting a bus.

The insurer denied the claim, arguing the incident was not an 'accident' under the Schedule and that the applicant failed to submit her application within 90 days.

The arbitrator found that the applicant fell while alighting from the bus, meaning the use or operation of an automobile caused the incident.

Furthermore, although the applicant failed to submit the application within 90 days, the insurer was estopped from relying on this defence due to the adjuster's representations that the claim was being processed.

The appellant applied for arbitration regarding accident benefits but withdrew her application shortly after the pre-hearing discussion.

The arbitrator found the application was entirely without merit, denied the appellant her arbitration expenses, and ordered a global penalty of $2,700 against the appellant and two other applicants under section 282(11.2) of the Insurance Act.

On appeal, the Director's Delegate upheld the denial of expenses and the finding that the application was frivolous and an abuse of process.

However, the Delegate amended the penalty order to impose individual liability of $900 on each applicant, rather than a global amount.

The respondent was injured in a motor vehicle accident while vacationing in Vietnam.

She applied for statutory accident benefits under a standard motor vehicle liability policy issued by the appellant.

The appellant denied the claim on the basis that the policy applies only to accidents in Canada, the United States, or on a vessel travelling between the ports of those countries.

An arbitrator initially held that the Statutory Accident Benefits Schedule operated without territorial limitation.

On appeal, the Director of Arbitrations allowed the appeal, finding that the Schedule does not operate independently of the contract of insurance, which contains a valid territorial limitation.

The respondent was therefore not eligible to receive benefits for the accident in Vietnam.

The appellant insurer appealed an arbitration decision finding it responsible for paying the respondent pedestrian's accident benefits.

The pedestrian was struck by a vehicle insured by the appellant.

She applied for benefits under a policy held by her former common-law partner, insured by the respondent insurer.

The arbitrator found that the pedestrian and the named insured were not spouses at the time of the accident because they had ceased cohabiting for over a year.

On appeal, the Director's Delegate upheld the decision, finding that a temporal connection is implicit in the definition of "spouse" under the Insurance Act and the standard automobile policy, and that non-married spousal status ends when the parties cease to cohabit in a relationship of some permanence.

The applicant, a tailor, was involved in multiple motor vehicle accidents and sought statutory accident benefits from two insurers.

The insurers terminated or refused weekly income benefits, arguing the applicant was not substantially unable to perform the essential tasks of his employment.

The arbitrator found that the applicant exaggerated his symptoms and that surveillance evidence contradicted his claims of severe disability.

The arbitrator concluded the applicant failed to prove a substantial inability to perform his essential tasks and dismissed the claims for weekly income benefits, though expenses were awarded to the applicant.

The applicant was injured in a motor vehicle accident and received weekly income benefits until the insurer terminated them.

The applicant applied for arbitration, claiming ongoing weekly income benefits, a special award, interest, and expenses.

The arbitrator found that the applicant was substantially unable to perform the essential tasks of her employment as a seamstress due to a herniated disc caused by the accident.

The arbitrator preferred the evidence of the applicant's treating orthopaedic surgeon over the insurer's medical experts.

The applicant was awarded ongoing weekly income benefits, interest, and expenses, but the claim for a special award was dismissed as the insurer's termination of benefits was not unreasonable.

The Insurer brought a motion for the production of accident benefit claims files from Economical Mutual Insurance Company relating to two third parties, alleging that the Applicant's claim was part of a scheme involving fraudulent employment information.

The Arbitrator ordered the production of the requested files, excepting any documents relating to the setting of claims reserves, and directed that notice be given to the affected third parties and the other insurer to allow them to make submissions.

The applicant claimed statutory accident benefits, alleging she was a passenger in a vehicle involved in a collision in a mall parking lot.

The insurer denied the claim, asserting she was not in the vehicle.

After hearing evidence from the applicant, the driver, the other driver, and the investigating police officer, the arbitrator found the applicant's evidence implausible and contradictory.

The independent witnesses confirmed no women were in the vehicle.

The arbitrator concluded the applicant was not involved in the accident, dismissed her claims for benefits and a special award, and ordered her to repay interim benefits with interest.

Finding the claim abusive and vexatious, the arbitrator also ordered the applicant to pay the insurer's $1,000 assessment fee.

The applicant sought statutory accident benefits, claiming she was a passenger in a vehicle struck by a truck.

The insurer denied the claim on the basis that she was not an occupant of the vehicle.

At the arbitration hearing, the arbitrator found the evidence of the police officer and the truck driver, who testified they saw no one else in the vehicle, more credible than the applicant and her witnesses.

The arbitrator concluded the applicant was not an occupant of the vehicle, dismissed her claim as an abuse of process, and ordered her to pay $2,000 in expenses to the insurer.

The applicant, a pedestrian, was struck by a motor vehicle insured by Economical.

She applied for statutory accident benefits from Wellington under a policy issued to her future husband, claiming she was his spouse at the time of the accident.

The arbitrator found that although the applicant and the named insured had previously cohabited and had children together, they had ceased cohabiting for over a year prior to the accident.

Consequently, the applicant did not meet the definition of 'spouse' under section 224(1) of the Insurance Act at the time of the accident and was not an 'insured person' under the Wellington policy.

Economical was held liable to pay the statutory accident benefits.

The applicant sought assessment of expenses related to the expert testimony of his family doctor at an arbitration hearing.

The doctor billed for preparation, travel, and attendance time.

The arbitrator held that under section 5(1)2 of Ontario Regulation 664, expert witness expenses are limited to the reasonable time the expert is in attendance at the hearing site, and do not include pre-arbitration preparation or travel time.

The insurer was ordered to pay $112.50 for the 45 minutes the doctor spent at the hearing.

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

The Insurer denied the claim, alleging the Applicant knowingly misrepresented his driving history on his insurance application by failing to disclose a prior licence suspension.

The arbitrator found that the Applicant had received notice of his licence suspension and knowingly misrepresented his driving history.

The misrepresentation was material, as the Insurer would have charged a higher premium had it known the truth.

The Applicant was precluded from receiving benefits and denied his arbitration expenses.

The applicant failed to attend a scheduled medical examination without a reasonable excuse, resulting in a $250 no-show fee assessed by the physician.

The insurer deducted this fee from the applicant's ongoing weekly accident benefits.

The applicant applied for arbitration to dispute the deduction.

The arbitrator held that there is no statutory authority under the Insurance Act or the Statutory Accident Benefits Schedule allowing an insurer to set off a no-show fee against an insured's entitlement to benefits.

The insurer was ordered to repay the $250 with interest, and the applicant was awarded expenses.

The Applicant was injured in a motor vehicle accident and received weekly income benefits until the Insurer terminated them based on an independent medical examination.

The Applicant sought reinstatement of benefits, arguing he remained unable to perform his physically demanding job as a fence installer.

The Arbitrator found the Applicant was substantially unable to return to work until June 3, 1993, and ordered benefits paid to that date.

The Arbitrator also determined that the Applicant's accrued vacation pay should be allocated over the period it was earned for the purpose of calculating his gross weekly income.

The Applicant's claim for a special award was dismissed, as the Insurer's reliance on its medical report to terminate benefits was not unreasonable.