OFSCDRS 1993

The applicant, a university student, was injured in a motor vehicle accident while a passenger in a vehicle insured by Axa Insurance.

He applied for no-fault benefits from both Axa and his mother's insurer, Economical Mutual.

The issue was whether the applicant was 'principally dependent for financial support' on his mother, which would make Economical responsible.

The arbitrator conducted a detailed analysis of the applicant's expenses and financial resources, including student loans, employment income, and Canada Pension Plan orphan benefits.

The arbitrator concluded that while the mother made the single greatest contribution to his support, the applicant's other financial resources were greater than her contribution.

Therefore, he was not principally dependent on his mother, and Axa Insurance was responsible for paying the no-fault benefits.

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

She applied for arbitration, claiming ongoing weekly income benefits and reimbursement for various medical, rehabilitation, and care expenses.

The arbitrator found that the applicant suffered from chronic pain resulting from the accident, which substantially disabled her from performing the essential tasks of her employment as a laboratory manager until August 14, 1992.

After that date, surveillance evidence and functional capacity evaluations demonstrated she was no longer substantially disabled.

The arbitrator awarded weekly income benefits for the closed period, along with specific supplementary medical, rehabilitation, and care expenses, and arbitration expenses.

The applicant was injured in a motor vehicle accident and received physiotherapy treatments.

His employment insurer paid 80% of the cost, and the no-fault insurer paid the remaining 20%.

The applicant sought full reimbursement from the no-fault insurer, arguing that the employment benefits were not 'reasonably available' because they reduced his lifetime maximum coverage.

The arbitrator dismissed the claim, finding that the employment benefits were reasonably available and that the no-fault insurer is a secondary insurer under the No-Fault Benefits Schedule.

The applicant was awarded his arbitration expenses for bringing an arguable case on a novel issue.

The applicant, a taxi driver, was injured in a motor vehicle accident and received weekly income benefits.

The insurer terminated benefits on the basis that the applicant was no longer substantially unable to perform his essential tasks.

The parties agreed prior to the hearing that the applicant had been overpaid due to an incorrect calculation of his pre-accident income.

The arbitrator found that the medical evidence did not support the applicant's claimed level of disability, concluding that he exaggerated his symptoms and failed to follow medical advice to exercise and return to work.

The arbitrator held that the applicant was not entitled to further benefits and ordered him to repay the $7,936 overpayment.

The applicant was awarded his arbitration expenses.

The applicant was injured in a motor vehicle accident and received weekly disability benefits until they were terminated by the insurer.

The parties attended mediation and the insurer paid a $6,000 lump sum, which it argued was a full and final settlement of the weekly benefits claim.

The applicant argued the sum was only a reinstatement of benefits for a limited period and that she did not agree to a final release.

The arbitrator found that the mediator's report did not clearly indicate a full and final release and that the applicant did not understand the settlement to be final.

The arbitrator held that the weekly benefits claim was not settled and allowed the matter to proceed to arbitration.

The applicant was injured in a motor vehicle accident and claimed weekly income benefits from the insurer.

The arbitrator found that the applicant was substantially unable to perform the essential tasks of his self-employment in the video game business from the date of the accident until April 16, 1992.

However, because the applicant operated a cash business and failed to provide credible evidence of his pre-accident or post-accident income, his benefits were calculated at the statutory minimum of $185.60 per week.

As the insurer had already paid benefits exceeding the applicant's total entitlement, the applicant was ordered to repay the overpayment of $6,075.64.

The applicant was awarded the expenses of the arbitration.

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 sought an award for expenses incurred in an arbitration proceeding against the Insurer.

The Senior Arbitrator granted the request, noting that expenses should generally be awarded to an applicant unless the application was frivolous or vexatious, or the applicant unreasonably prolonged the proceedings.

The parties were encouraged to agree on the quantum, failing which the arbitrator remained seized to assess the expenses.

The Applicant was injured in a motor vehicle accident and claimed no-fault benefits.

A priority dispute arose between State Farm (the father's insurer) and Pilot (the insurer of the vehicle the Applicant occupied).

The issue was whether the 20-year-old Applicant, who lived at home and contributed his full-time earnings to a family pool controlled by his father, was "principally dependent for financial support" on his parents under section 3(2) of the No-Fault Benefits Schedule.

The arbitrator found that the Applicant's financial contributions exceeded his share of household expenses, making him essentially self-supporting.

Despite his social and cultural dependence on his father, the statutory test requires financial dependence.

The arbitrator concluded the Applicant was not principally dependent on his parents and must seek benefits from Pilot.

The Applicant was injured in a motor vehicle accident and applied for weekly no-fault benefits.

He was already receiving no-fault benefits from a previous accident, long-term disability benefits, and Canada Pension Plan (CPP) disability benefits.

The Insurer argued these payments were deductible from his current no-fault benefits.

The arbitrator held that all three benefit payments were payments for loss of income and were therefore deductible from the Applicant's no-fault benefits.

The arbitrator declined to rule on whether the Applicant should have applied under section 12 or 13 of the No-Fault Benefits Schedule, as the deductibility issue rendered it moot.

The Applicant was awarded expenses for the deductibility issue but not for the disability issue, which he failed to object to in a timely manner.

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

He sought weekly income benefits under section 12 of the No-Fault Benefits Schedule, arguing he was self-employed at the time of the accident despite receiving workers' compensation for a prior injury.

The arbitrator found that the Applicant was neither employed nor self-employed in the twelve months prior to the accident, making him ineligible under section 12.

He was found entitled to benefits under section 13 at $185.00 per week.

The arbitrator declined to rule on the deductibility of workers' compensation benefits due to a lack of jurisdiction, as the issue had not been mediated.

The applicant, a taxicab driver, was injured in a motor vehicle accident and subsequently developed post-traumatic stress disorder and a driving phobia.

The insurer terminated her weekly income benefits, arguing she had returned to her pre-accident condition.

The arbitrator found that the applicant suffered a substantial inability to perform the essential tasks of her occupation due to the psychological injuries caused by the accident.

However, because the applicant fabricated trip sheets to inflate her pre-accident income, the arbitrator awarded the minimum weekly benefit of $185.60 and reduced her expense award to two-thirds.

The applicant was injured in a motor vehicle accident and received statutory accident benefits until July 1991.

She claimed ongoing entitlement to weekly income benefits, childcare benefits, and housekeeping expenses due to a right ulnar nerve problem that developed months after the accident.

The insurer denied ongoing benefits and claimed an overpayment, arguing that the applicant's pre-existing workers' compensation pension should have been deducted from her weekly benefits.

The arbitrator found that the applicant failed to establish on a balance of probabilities that her ulnar neuropathy was caused by the motor vehicle accident, as there was no evidence of direct trauma to her elbow.

Consequently, her claims for ongoing benefits were dismissed.

However, the arbitrator also held that the applicant's workers' compensation pension for a permanent partial disability was not a payment for loss of income under section 13(3) of the No-Fault Benefits Schedule, and therefore was not deductible.

The insurer's claim for repayment of the alleged overpayment was dismissed.

The Applicant sought weekly income benefits following a motor vehicle accident, claiming it caused a disabling psychological injury (panic disorder).

The Insurer had reduced and then disputed his entitlement to benefits, arguing his anxiety was caused by severe alcohol and substance abuse rather than the minor accident.

The arbitrator found that the Applicant's ongoing incapacity was the result of his long-standing alcohol dependence and withdrawal, compounded by personal stressors, rather than the accident.

The arbitrator also determined that for the purpose of calculating pre-accident income, real estate commissions are earned on the date of closing, not the date of the agreement of purchase and sale.

The claim for ongoing benefits and a special award was dismissed.

The applicant was injured in a motorcycle accident and sought no-fault benefits to retrain as a commercial airline pilot, arguing he could no longer work as a truck driver due to knee injuries.

The arbitrator found that the applicant had successfully returned to work as a truck driver for a trial period and failed to provide medical evidence showing he could not continue in that occupation.

The arbitrator concluded that retraining as a pilot was not a reasonable expense resulting from the accident and dismissed the claim for occupational training benefits.

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

She subsequently began receiving Canada Pension Plan (CPP) disability benefits.

The Insurer terminated her weekly benefits and sought repayment of the overpayment resulting from the retroactive CPP award.

The Applicant also claimed the cost of an airline ticket to Italy as a medical expense, arguing it was recommended by her doctor for therapy.

The Arbitrator held that CPP benefits are deductible from weekly income benefits under section 13(3) of the No-Fault Benefits Schedule.

The Arbitrator ordered the Applicant to repay the $10,224.40 overpayment through an offset against future benefits.

The claim for the airline ticket was dismissed as it was not a necessary medical expense.

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

The applicant applied for arbitration but subsequently signed a release settling all claims for $2,640 during a pre-hearing discussion.

Shortly after signing, the applicant had second thoughts and sought to proceed with the arbitration.

The arbitrator held that the release was a valid, final settlement reached without fraud, coercion, or unconscionability, and therefore the arbitration could not proceed.

The applicant was awarded expenses incurred after the date of the release.

The applicant, a retired 63-year-old, was injured in a motor vehicle accident and received non-income weekly benefits until the insurer terminated them.

The applicant sought ongoing benefits under section 13 of the No-Fault Benefits Schedule, arguing he suffered a substantial inability to perform his essential tasks.

The arbitrator defined 'essential tasks' as activities connected to the ongoing business of living, excluding casual social activities and informal volunteering.

The arbitrator found that while the applicant's physical abilities were significantly modified initially, his condition had improved by October 6, 1992, such that he was no longer substantially disabled.

The applicant was awarded benefits for the closed period from November 11, 1991, to October 6, 1992, along with interest and arbitration expenses.

The applicant was injured in a motor vehicle accident and received weekly, childcare, and housekeeping benefits until the insurer terminated them, claiming an overpayment.

The insurer relied on a medical report and a nurse's assessment to conclude the applicant was no longer disabled.

The arbitrator found the nurse was not qualified as an expert and her assessment lacked an objective basis, while the treating orthopaedic surgeon's testimony was contradictory and unreliable.

Relying on the applicant's credible testimony regarding her ongoing physical limitations, the arbitrator ordered the reinstatement of all benefits and dismissed the insurer's claim for repayment.

The Applicant was injured in a motor vehicle accident and claimed weekly income benefits based on two jobs: one at Rayette Forest Products and another delivering newspapers for The Toronto Star.

The Insurer paid benefits based on the first job but disputed the income from the newspaper delivery, as the Applicant had not reported it to Revenue Canada and lacked business records.

The Insurer also alleged the Applicant had returned to work delivering newspapers after the accident, relying on surveillance evidence.

The Arbitrator found that the Applicant's income from the newspaper delivery was corroborated by the testimony of a district manager and business records.

The Arbitrator also concluded that the surveillance evidence misidentified the Applicant's cousin as the Applicant, and that the Applicant had not returned to work.

The Applicant was awarded the maximum $600 per week in income benefits and his arbitration expenses, but his claim for a special award was denied because the Insurer's questioning of his proof was reasonable.