OFSCDRS 1994

York Fire applied to revoke a previous arbitration order which found that Dorna Osbourne was the spouse of its insured, Winston Smart, making York Fire responsible for the applicant's statutory accident benefits.

York Fire introduced new evidence demonstrating that both Osbourne and Smart had lied under oath during the initial hearing about their marital histories and continuous cohabitation.

The arbitrator admitted the new evidence, found the witnesses' credibility severely undermined, and revoked the previous order.

The arbitrator concluded that Osbourne and Smart were not spouses at the time of the accident, and ordered Allstate to respond to the applicant's claims.

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

A priority dispute arose between the insurer of the vehicle he was in (State Farm) and his brother's insurer (Progressive).

The arbitrator found the applicant was principally dependent on his brother for financial support, making Progressive liable.

The applicant also claimed weekly income benefits based on a job offer made shortly before the accident.

The arbitrator accepted that a legitimate offer of employment existed but found the applicant's accident-related disability resolved by mid-June 1991.

Weekly income benefits were awarded for that limited period, along with arbitration expenses.

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

The applicant disputed the termination and applied for arbitration.

At the hearing, the applicant's representative requested an adjournment, which was denied due to a lack of reasonable grounds and a history of uncooperative behaviour, including failing to attend a pre-hearing discussion and medical examinations.

The applicant withdrew from the hearing.

The arbitrator heard evidence from the insurer, including medical reports indicating the applicant was exaggerating his disability.

The arbitrator dismissed the applicant's claim for ongoing benefits and denied his request for arbitration expenses.

The applicant was injured in a motor vehicle accident and received statutory accident benefits, which were later terminated by the insurer.

The applicant applied for mediation but walked out within five minutes of the meeting's commencement, refusing to participate.

The mediator issued a report stating that mediation did not take place.

The applicant then applied for arbitration.

The arbitrator held that the applicant was not entitled to proceed to arbitration because the statutory requirement to seek and fail at mediation requires meaningful participation in good faith, not merely filing forms and walking out.

The applicant, a high school student injured in a motor vehicle accident, had a legitimate offer for a summer job at the time of the accident.

The insurer paid increased weekly benefits during the summer employment period but reduced them after the job would have ended.

The applicant sought to have the higher benefit rate continue indefinitely.

The arbitrator held that under section 12 of the Statutory Accident Benefits Schedule, the weekly benefit for an insured with a time-limited employment offer is based on the contract of employment only for the expected duration of that employment.

After the summer job period ended, the applicant's benefits were correctly reduced to the statutory minimum of $185.60 per week.

The applicant was awarded expenses due to the novel legal question.

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

The applicant sought ongoing benefits, claiming a hearing loss resulting from the accident prevented her from working as a waitress.

The arbitrator found the hearing loss was a pre-existing condition and dismissed the claim for ongoing benefits.

The insurer sought repayment of an overpayment, arguing the applicant's pre-accident income was misstated.

The arbitrator agreed, finding the applicant had no earnings in the four weeks prior to the accident, and ordered the applicant to repay the overpayment with interest.

The applicant applied for caregiver benefits under the Statutory Accident Benefits Schedule, claiming he quit his job to provide full-time care for his son who was injured in a motor vehicle accident.

The insurer had paid some benefits but later sought repayment, arguing the payments were made in error.

The arbitrator found that the son's injuries did not require full-time care beyond normal parental duties and that the applicant had quit his jobs for economic reasons, not to provide care.

The arbitrator dismissed the claim for additional benefits and ordered the applicant to repay $36,295.00 to the insurer, finding that the applicant had misled the insurer about his employment and caregiving status.

The applicant was injured in a motor vehicle accident and received weekly statutory accident benefits from the insurer as a homemaker under section 13 of the Schedule.

The insurer terminated benefits on the basis that the applicant was fit to resume her household duties.

The arbitrator found that the applicant was primarily a homemaker at the time of the accident, but concluded based on medical records, functional abilities evaluations, and surveillance that she no longer suffered a substantial inability to perform her essential daily tasks.

The application for ongoing weekly benefits and a special award was dismissed, though the applicant was awarded her arbitration expenses.

The applicant, a self-employed carpenter, was injured in a motor vehicle accident and applied for statutory accident benefits.

The parties disputed the calculation of his weekly income benefits.

The applicant argued his income should be based on the four weeks preceding the accident, utilizing a 'work-in-progress' accounting method for an unfinished renovation contract.

The arbitrator rejected this method because the partnership was not paid in full for the work and ultimately suffered a loss.

The applicant failed to establish his income exceeded the deemed statutory minimum.

The arbitrator ordered the insurer to pay the minimum weekly income benefit of $185.60, plus the applicant's arbitration expenses.

The Applicant was injured in a motor vehicle accident and claimed expenses for a Health Care Aide to assist her at home, arguing these were 'nursing services' under section 6(1)(a) of the Statutory Accident Benefits Schedule, which has no monthly limit.

The Insurer argued the services were 'care' benefits under section 7, subject to a $3,000 monthly limit.

The Arbitrator held that the services provided by the Health Care Aide were best described as 'care' rather than 'nursing services,' as they were primarily focused on assisting with daily tasks rather than active treatment or rehabilitation.

Therefore, the benefits were limited to $3,000 per month under section 7.

The applicant was injured in a motor vehicle accident and received statutory accident benefits, including weekly income benefits, which the insurer terminated on the basis that she was no longer substantially unable to perform the essential tasks of her pre-accident employment as a dental assistant.

The insurer relied on surveillance evidence and an independent medical examination suggesting she could return to work.

The arbitrator preferred the evidence of the applicant's treating professionals, finding that she remained unable to perform the specific, sustained physical tasks required of a dental assistant.

The applicant was awarded ongoing weekly income benefits, outstanding housekeeping expenses, and arbitration expenses.

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

The applicant sought arbitration to reinstate the benefits, claiming a substantial inability to perform essential tasks.

The arbitrator reviewed conflicting medical evidence and preferred the functional abilities evaluation of an occupational therapist, which demonstrated the applicant could perform his essential daily tasks.

The claim for ongoing weekly benefits was dismissed, though the applicant was awarded the expenses of the arbitration.

The Applicant was injured in a motor vehicle accident and received weekly income benefits until they were terminated by the Insurer.

The parties attended mediation and the Insurer paid $750, which it claimed was a full and final settlement of all past and future weekly income benefits.

The Applicant argued the settlement only covered benefits up to the date of mediation.

On a preliminary issue hearing, the Arbitrator found that the mediator's report was ambiguous and there was no clear agreement or release extinguishing the Applicant's right to future benefits.

The Arbitrator concluded there was no meeting of the minds regarding the scope of the settlement, and allowed the Applicant to proceed to arbitration for ongoing benefits.

The Applicant's husband died in a motor vehicle accident.

At the time, the family was receiving general welfare assistance, with the husband designated as the head of the household and receiving the cheques.

The Insurer denied the Applicant's claim for a $10,000 death benefit under section 11(1)(c) of the Statutory Accident Benefits Schedule, arguing she was principally dependent on welfare, not her husband.

The Arbitrator found that because the welfare payments were structured such that the Applicant had no independent access to the funds and relied on her husband to administer them, she was principally dependent for financial support on her late husband.

The Applicant was awarded the $10,000 death benefit.

The applicant, a self-employed taxi driver, was injured in a motor vehicle accident and claimed statutory accident benefits.

A dispute arose regarding the calculation of her pre-accident gross weekly income, as she operated on a cash basis and did not file tax returns.

The arbitrator found that the applicant's uncorroborated testimony and self-created trip sheets for only one week were insufficient to prove an income higher than the deemed minimum.

Consequently, her weekly income benefits were set at the minimum of $185.60.

The insurer's claim for repayment of benefits previously paid at a higher rate was dismissed, as the insurer failed to prove the payments were made through error or fraud.

The Applicant was injured when struck by a car while riding her bicycle.

The Insurer paid weekly income benefits but terminated them, arguing the Applicant failed to mitigate her damages by finding alternative part-time employment.

The Arbitrator found the Applicant had not acted inappropriately, given her significant job barriers, physical limitations, and ongoing education and physiotherapy.

The Arbitrator ordered the Insurer to pay ongoing weekly income benefits and awarded a $2,500 special award because the Insurer unreasonably withheld benefits.

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

The Insurer disputed his entitlement to weekly income benefits for a specific week, the amount claimed for lost income while attending physiotherapy, and his entitlement to chiropractic treatment.

The Arbitrator held that subsection 16(2) of the Schedule precluded the Applicant from receiving weekly income benefits for the week in question because he had returned to work for more than 90 days after the two-year anniversary of the accident.

The Arbitrator found the time claimed for physiotherapy attendance was reasonable, except for the week he was not working, but declined to order repayment.

The claim for chiropractic treatment was denied due to insufficient medical evidence.

The applicants, two young children severely injured in a motor vehicle accident, applied for statutory accident benefits.

A priority dispute arose between the father's former insurer and the insurer of the vehicle involved in the accident.

The father's former insurer claimed it had cancelled his policy for non-payment of premiums prior to the accident by sending a notice via registered mail.

The vehicle's insurer argued the cancellation was invalid because the notice was never received.

The arbitrator found that the former insurer had validly terminated the policy in accordance with the statutory requirements, as the notice was received at the destination post office in time to provide the required 15 days' notice.

Consequently, the vehicle's insurer was held responsible for paying the statutory accident benefits.

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

The insurer terminated benefits based on surveillance evidence showing the applicant working at a doughnut shop and a supermarket.

The applicant sought arbitration for ongoing benefits and a higher weekly rate based on alleged pre-accident income.

The arbitrator dismissed the applicant's claims, finding his evidence and financial documents lacked credibility.

The arbitrator ordered the applicant to repay an overpayment of $2,243.96 to the insurer and denied the applicant's request for expenses.

The Applicant was injured in a motor vehicle accident while riding his motorcycle and sought statutory accident benefits.

The Insurer terminated his weekly disability benefits, prompting the Applicant to apply for arbitration.

The Applicant claimed he was employed "under the table" at the time of the accident and thus qualified for income benefits under section 12 of the Schedule.

The Arbitrator found the Applicant's evidence regarding his employment lacked credibility and concluded he was not employed at the time of the accident.

Furthermore, the Arbitrator determined the Applicant was not entitled to non-earner benefits under section 13, as he was able to perform the bulk of his pre-accident activities of daily living.

The application was dismissed, and the Applicant was denied his arbitration expenses due to the lack of merit in his case.