Nicholaus Andreas De Koning

The insurer appealed and the claimant cross-appealed an Arbitrator's decision regarding attendant care benefits (ACBs) and a special award for unreasonably withheld income replacement benefits (IRBs) following a motor vehicle accident.

The Director's Delegate corrected mathematical and rate errors in the Arbitrator's ACB calculation, increasing the monthly amount to $1,615.32.

The Delegate upheld the Arbitrator's factual finding that the claimant did not require 24-hour supervisory care, preferring the insurer's occupational therapy evidence over the claimant's assessor, who was found to lack objectivity.

The Delegate also held that section 39(3) of the SABS does not bar retroactive ACB claims, as it governs the timing of payment rather than entitlement.

The insurer's appeal against the special award was dismissed, as evidence supported the finding that IRBs were unreasonably withheld.

Appeal from an arbitral decision concerning a priority dispute between insurers over statutory accident benefits.

The issue was when the respondent insurer received a “completed application” triggering the 90‑day notice period under s. 3(1) of O. Reg. 283/95 (Disputes Between Insurers).

The arbitrator held that the application became functionally complete when full spousal insurance details were received months later.

The court held that the application became functionally adequate earlier, once the insurer obtained sufficient information to begin reasonable investigations into potential priority insurers.

Because notice was given more than 90 days after that point and the savings provision in s. 3(2) did not apply, the appeal was allowed and the arbitration award set aside.

The applicant claimed statutory accident benefits following an alleged motor vehicle accident.

The insurer denied the claim, alleging the accident was staged and providing engineering evidence that the vehicles' damage was inconsistent with a collision.

After the applicant's counsel was removed from the record, the applicant failed to retain new counsel, communicate with the Commission, or attend the scheduled preliminary issue hearing despite receiving due notice.

The arbitrator dismissed the application for arbitration pursuant to section 7(1) of the Statutory Powers Procedure Act and ordered the applicant to pay the insurer's expenses, finding the claim appeared spurious and the applicant's inaction needlessly prolonged the process.

The applicant was injured in a motor vehicle accident and applied for statutory accident benefits, which were denied by the insurer.

The applicant failed to attend the preliminary issue hearing, as well as previous proceedings, and her previous counsel had been removed from the record.

The arbitrator dismissed the application for arbitration due to the applicant's failure to meet her onus to establish entitlement to the claims.

The insurer was awarded its reasonable expenses fixed at $3,150.40.

The applicant sought statutory accident benefits following a motor vehicle accident, claiming entitlement to 29 treatment plans, attendant care, housekeeping, and examination costs.

The arbitrator found the applicant lacked credibility, noting he minimized pre-accident health issues and submitted false invoices.

The arbitrator rejected the applicant's expert evidence and found the claimed treatments were not reasonable or necessary.

However, six treatment plans totaling $6,398.23 were payable because the insurer failed to respond to them, resulting in deemed approval under the Schedule.

All other claims were dismissed.

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

After disputes arose, the applicant applied for arbitration at the Financial Services Commission of Ontario.

The applicant's legal representative got off the record, and the applicant subsequently failed to attend both the pre-hearing conference and the arbitration hearing.

The arbitrator dismissed the application as abandoned and ordered the applicant to pay the insurer's expenses of the proceeding fixed at $750.

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

After her legal representative got off the record, the applicant failed to attend the pre-hearing conference and the arbitration hearing despite receiving written notice.

The arbitrator dismissed the application as abandoned and ordered the applicant to pay $750 in expenses to the insurer.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits from her insurer, including medical benefits, attendant care, housekeeping expenses, and the cost of examinations.

The insurer denied most of the claims, citing suspicions about the applicant's treatment provider, Osler Rehabilitation Centre.

The arbitrator dismissed the claims for attendant care, medical benefits beyond the Pre-approved Framework, and examination costs, finding the applicant's evidence lacked credibility and failed to establish the expenses were reasonable and necessary.

However, the arbitrator granted housekeeping benefits for a limited period, noting the applicant's initial need for assistance.

The claim for a special award was dismissed, as the insurer's delay in paying housekeeping benefits was not unreasonable given the questionable nature of the initial evidence.

The applicants sought statutory accident benefits following a motor vehicle collision.

The insurer denied the claims, alleging that the collision was staged and that the applicants wilfully misrepresented material facts.

At a preliminary issue hearing, the arbitrator considered evidence from the police officer, the occupants of the other vehicle, and accident reconstruction engineers.

The arbitrator rejected the insurer's theory that the collision was staged, finding no evidence of a conspiracy between the drivers and noting that the occupants of the other vehicle did not know the applicants.

The arbitrator concluded that the applicants were involved in an 'incident' within the meaning of section 2(1) of the Schedule and did not wilfully misrepresent material facts.

The issue of impairments was reserved for the main arbitration hearing.

The applicant sought payment for various medical treatment and assessment plans, interest on overdue payments, and a special award following a motor vehicle accident.

The arbitrator found that several claims had already been paid by the insurer, awarding interest on those late payments.

Other claims were denied due to the applicant's failure to attend insurer's examinations without reasonable explanation, and due to significant factual inconsistencies and omissions regarding her pre-existing medical history in the submitted treatment plans.

The claim for a special award was dismissed as there was no evidence of bad faith by the insurer.

Each party was ordered to bear its own arbitration expenses.

Following a preliminary issue hearing where the Insurer successfully proved the Applicants were not involved in an accident, the Insurer sought its legal expenses.

The Arbitrator found the Insurer was entirely successful and entitled to its reasonable expenses.

The Arbitrator fixed the Insurer's expenses at $7,500, inclusive of fees and disbursements, and ordered the Applicants to be jointly and severally liable for this amount.

The Applicant claimed statutory accident benefits following an alleged motor vehicle collision.

The Insurer denied the claim, arguing that the collision was staged and did not constitute an 'accident' under the Schedule.

At a preliminary issue hearing, the arbitrator reviewed expert engineering evidence and found numerous inconsistencies between the physical damage to the vehicles and the reported sequence of events.

The arbitrator concluded that the Applicant failed to prove on a balance of probabilities that he was involved in an accident, and dismissed the claim.

The applicant claimed statutory accident benefits following an alleged motor vehicle collision.

The insurer denied the claim on the basis that no 'accident' occurred.

At a preliminary issue hearing, the arbitrator considered engineering evidence regarding the physical damage to the vehicles, which was inconsistent with the reported mechanics of the collision.

The arbitrator also noted numerous suspicious circumstances, including pre-existing damage, the storage of the vehicle, and inconsistencies in the reporting of injuries.

The arbitrator concluded that the applicant failed to prove on a balance of probabilities that she was involved in an accident as defined in the Schedule.

The applicant sought statutory accident benefits following an alleged motor vehicle collision.

The insurer denied the claim, arguing that no 'accident' occurred.

At a preliminary issue hearing, the arbitrator reviewed engineering evidence and found significant inconsistencies between the physical damage to the vehicles and the reported mechanics of the collision.

Given these inconsistencies and other suspicious circumstances, including pre-existing vehicle damage and unsupported medical claims, the arbitrator concluded the applicant failed to prove on a balance of probabilities that she was involved in an accident as defined in the Schedule.

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

She initially sent her application to the wrong insurer, resulting in a delay in notifying the respondent insurer.

The respondent denied benefits, citing the delay and a lack of information.

The arbitrator found that the applicant had a reasonable explanation for the delay and that the respondent had failed egregiously in its responsibilities by not expeditiously obtaining her file from the other insurer.

The arbitrator awarded the applicant housekeeping benefits for 104 weeks, caregiver benefits for 52 weeks, and a medical benefit for chiropractic treatment.

Additionally, the arbitrator ordered the respondent to pay a special award of $5,000 because it had unreasonably withheld the payment of benefits.

The applicant was injured in a motor vehicle accident and sought payment for a psychological assessment and two treatment plans from the insurer.

The arbitrator found the psychological assessment was not reasonable and necessary given the applicant's pre-existing psychological treatment and the early stage of rehabilitation.

The claim for the Osler treatment plan was denied due to lack of evidence.

However, the Chesswood treatment plan was found to be reasonable and necessary as it provided beneficial care after the applicant left the previous clinic.

The insurer was ordered to pay $2837.97 for the Chesswood plan plus interest.

The applicant, who suffered from pre-existing secondary progressive multiple sclerosis, was injured in a motor vehicle accident.

Following the accident, his mobility rapidly declined, necessitating a wheelchair-accessible vehicle.

The insurer denied the $41,761.45 claim for vehicle modifications, arguing the decline was the natural progression of his disease.

The arbitrator preferred the evidence of the applicant's treating neurologist, finding that the trauma and subsequent hospital deconditioning materially contributed to the rapid functional decline.

The claim for rehabilitation benefits was granted.

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

The insurer terminated housekeeping benefits and refused to pay for certain medical benefits and costs of examinations.

The arbitrator found that the applicant's testimony was not credible, noting he did not take time off work and did not mention the accident to his family doctor for two years.

The arbitrator dismissed the claims for medical benefits, housekeeping benefits, and costs of examinations, finding them not reasonable or necessary.

The applicant was injured in a motor vehicle accident and applied for a non-earner benefit but failed to submit a Disability Certificate for over a year.

The insurer denied benefits for the period prior to the submission of the certificate.

The arbitrator found that the applicant's drug addiction and mental illness, which severely impaired her motivation and ability to function, provided a reasonable explanation for the delay under section 31 of the Statutory Accident Benefits Schedule.

The applicant was therefore not precluded from claiming the benefit for the disputed period.

Following a preliminary issue hearing where the insured's application for arbitration was dismissed on the basis that he failed to prove he was involved in an 'accident', the insurer sought its legal expenses and disbursements.

The arbitrator found that the insurer was the successful party and was entitled to its expenses.

The arbitrator awarded the insurer $9,839.20, which included legal fees, disbursements, and the maximum allowable amounts for its expert witness's preparation and attendance, noting that the insurer's expert evidence was preferred because the expert inspected both vehicles closer to the date of the incident.