OFSCDRS 1994

The applicant was injured in a rear-end motor vehicle accident and claimed weekly income benefits, alleging a substantial inability to perform her essential tasks in her family-run tile business.

The insurer denied the benefits.

At arbitration, surveillance evidence contradicted the applicant's testimony regarding her physical limitations and work attendance.

The arbitrator found the applicant's evidence unreliable and concluded she failed to prove a substantial inability to perform her essential job tasks.

The claim for weekly benefits was dismissed, but the applicant was awarded her expenses of the arbitration.

The applicant, a self-employed gas station owner, was injured in a motor vehicle accident and claimed statutory accident benefits.

The insurer terminated his weekly income benefits on January 3, 1991.

The applicant sought reimbursement for expenses incurred in hiring replacement workers to run his business while he was disabled, as well as ongoing weekly income benefits.

The arbitrator held that the cost of replacement labour is a business expense and cannot be claimed as a rehabilitation expense under section 6(1)(f) of the Schedule, nor under section 12.

However, the arbitrator found that the applicant was substantially disabled from performing his essential tasks until February 1, 1991, and ordered the insurer to pay weekly income benefits of $211.98 until that date, plus interest and arbitration expenses.

The applicant was injured in a motor vehicle accident while a passenger on a bus and received weekly income benefits.

She returned to work but later resigned, claiming an inability to perform her essential tasks due to accident-related injuries.

The arbitrator found that the applicant did not suffer a substantial inability to perform the essential tasks of her employment and denied ongoing benefits.

The arbitrator also ordered the applicant to repay benefits received while she was working, as she failed to disclose her return to work.

The insurer's request for a special award for a frivolous application was denied, and the applicant was awarded her arbitration expenses.

The appellant appealed an arbitrator's decision that her application for arbitration was barred by the two-year limitation period under s. 281(5) of the Insurance Act.

The appellant argued that the insurer's conduct estopped it from relying on the limitation period and that the notice of termination was insufficient.

The Director of Arbitrations dismissed the appeal, finding no error in the arbitrator's conclusion that the appellant and her counsel were aware of the termination date and that the insurer's conduct did not induce them to believe the limitation period would not be relied upon.

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

She applied for ongoing benefits, claiming she was substantially unable to perform her essential tasks as a homemaker due to a knee injury.

The arbitrator dismissed the claim for ongoing benefits, finding that the medical evidence, surveillance video showing her performing tasks without apparent discomfort, and her history of non-compliance with treatment indicated she was no longer substantially disabled.

The claim for a special award was also dismissed, but the applicant was awarded her arbitration expenses.

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

The insurer refused to pay for chiropractic treatments after July 30, 1993, arguing they were no longer reasonable or necessary.

The arbitrator found that the ongoing chiropractic care constituted therapeutically necessary supportive care rather than elective maintenance care, given the physical demands of the applicant's work.

The arbitrator also ruled that while the insurer had no statutory right to require a medical examination for a claim involving only medical and rehabilitation benefits, the resulting medical report was admissible because the applicant attended voluntarily.

The insurer was ordered to pay the outstanding chiropractic and transportation expenses, plus the costs of the arbitration.

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

The Insurer terminated weekly income benefits, arguing she was no longer substantially unable to perform her essential tasks.

The Applicant sought ongoing benefits and a special award.

The arbitrator found the Applicant was entitled to weekly income benefits for a limited period following the termination, as her ongoing disabilities after that period were attributable to pre-existing medical conditions and subsequent slip and fall accidents, not the motor vehicle accident.

The claim for a special award was dismissed as the Insurer did not unreasonably withhold payments.

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

The insurer terminated her weekly benefits, and the applicant sought arbitration to claim benefits for the period between December 1991 and May 1993.

The arbitrator found that the applicant had a pre-existing disability and failed to prove that the accident caused or significantly contributed to her inability to perform her homemaking tasks during the disputed period.

The arbitrator accepted the insurer's medical evidence that the applicant was substantially able to perform her essential tasks.

The claim for weekly benefits was dismissed, but the applicant was awarded her arbitration expenses.

The applicant, an 18-year-old, was severely injured in a motor vehicle accident while driving a stolen vehicle.

He applied for statutory accident benefits from his parents' insurer, Simcoe & Erie, and the insurer of the stolen vehicle, Pilot.

The issue was which insurer was liable to pay the benefits, which depended on whether the applicant was "principally dependent for financial support" on his parents at the time of the accident.

The arbitrator reviewed the applicant's living arrangements and financial support in the years leading up to the accident.

The arbitrator found that the applicant had returned to live with his parents in the months prior to the accident because he had no independent means of support.

Consequently, the applicant was principally dependent on his parents, making Simcoe & Erie liable to pay the statutory accident benefits.

The appellant sought to appeal or revoke a settlement order and an arbitrator's decision on expenses arising from a statutory accident benefits dispute.

The Director of Arbitrations refused to extend the time to appeal the settlement order, finding no apparent grounds as the consent order and release were clear and the appellant had acted in accordance with them.

The request to revoke the settlement order was dismissed because there was no material change in circumstances or error.

The appeal of the arbitrator's decision on expenses was also dismissed, as the arbitrator had sufficient evidence to support her findings of fact and properly exercised her discretion in determining reasonable expenses.

The appellant's request for expenses of the proceedings was denied.

The applicant was injured in a motor vehicle accident and claimed statutory accident benefits for moving and snow clearing expenses.

The insurer paid a portion of the moving expenses but denied the rest.

The arbitrator found that the applicant required assistance with moving and snow clearing due to his injuries.

The arbitrator awarded $70 for snow clearing and a portion of the moving expenses, deducting the estimated cost the applicant would have incurred had he moved himself.

The claim for a special award was dismissed as the insurer had not unreasonably withheld payments.

The insurer brought a preliminary issue motion arguing that the insured was precluded from proceeding with his arbitration for ongoing weekly income benefits because he refused to attend a medical examination.

The insured argued that the insurer's right to require a medical examination ended when it terminated his benefits.

The arbitrator held that section 23(2) of the Statutory Accident Benefits Schedule allows an insurer to require a medical examination to evaluate an ongoing claim even after benefits have been terminated.

The arbitrator found the insurer's request for a follow-up examination reasonable and ordered that the insured is precluded from proceeding with the arbitration unless he makes himself reasonably available for the examination.

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

The applicant applied for arbitration to determine her ongoing entitlement to weekly benefits and whether they should be calculated under section 12 or 13 of the Schedule.

The insurer brought a motion to include the issues of repayment of overpaid benefits and the deductibility of CPP and Old Age Pension benefits.

The arbitrator dismissed the insurer's motion, finding that the insurer's proposed issues did not naturally or consequentially flow from the matters referred to arbitration by the applicant.

The applicant's husband was fatally injured in a motor vehicle accident while driving his own uninsured vehicle.

The applicant sought death benefits and funeral expenses from the insurer of the other vehicle involved in the collision.

The insurer denied the claim, arguing the deceased was not an 'insured person' under the Statutory Accident Benefits Schedule.

The arbitrator found that while the deceased did not meet the Schedule's definition, he did fall within the expanded definition of 'insured person' under section 2.2.3(g) of the O.P.F. 1 standard policy issued by the insurer.

The insurer was bound by the broader terms of its approved policy, entitling the applicant to the claimed benefits.

The applicant was injured in a motor vehicle accident and received weekly income benefits from the insurer until the insurer stopped payments, alleging an overpayment.

The applicant sought arbitration to reinstate benefits and determine the proper quantum.

The arbitrator found that the applicant suffered only soft tissue injuries and, relying on surveillance evidence and orthopaedic opinion, concluded he was not substantially unable to perform his pre-accident employment.

The arbitrator also found the applicant failed to prove his pre-accident income exceeded the minimum threshold.

Consequently, the arbitrator ordered the applicant to repay $14,086.40 in overpaid benefits, as the overpayment resulted from error or fraud regarding his income.

The applicant, a minor who suffered severe injuries after being struck by a motor vehicle, applied for statutory accident benefits from two insurers.

Allstate paid benefits to date, while York Fire denied liability.

On a preliminary issue hearing, the arbitrator ordered both insurers to share equally in the payment of interim benefits pending the final arbitration to determine priority.

The arbitrator found jurisdiction to make interim orders under section 279(4.1) of the Insurance Act and held that the applicant established a prima facie case for entitlement and urgency.

The Applicant was injured in a motor vehicle accident and received statutory accident benefits from the Insurer until they were terminated.

The parties participated in mediation and the Insurer claimed a final settlement of $8,375 was reached, issuing a cheque to the Applicant's counsel in trust.

The Applicant later sought to proceed to arbitration, arguing the settlement was only for a limited period.

The arbitrator found that a final and binding settlement had been concluded between competent parties represented by counsel, with no vitiating factors present.

As the dispute was settled, the Applicant was precluded from proceeding to arbitration.

The applicant, a bus passenger, claimed statutory accident benefits following a minor motor vehicle accident.

She sought weekly income benefits, care benefits for her mentally incapacitated son, housekeeping expenses, and a special award.

The arbitrator found the applicant was not a credible witness and that her ongoing complaints were related to pre-existing conditions rather than the accident.

The claims for weekly income benefits, housekeeping expenses, and a special award were dismissed.

The applicant was awarded care benefits for a limited period and her arbitration expenses.

The applicant was injured in a motor vehicle accident in November 1990 and received weekly income benefits from the first insurer until October 1992.

She was involved in a second accident in April 1992, involving a second insurer.

The applicant sought further weekly income benefits and rehabilitation expenses, while the first insurer sought repayment from the second insurer for benefits paid after the second accident.

The arbitrator found that the applicant was not substantially unable to perform the essential tasks of her occupation after October 1992 and dismissed the claim for further benefits and rehabilitation expenses.

The first insurer was held liable for benefits paid between the second accident and October 1992, and the applicant was ordered to repay $1,200 for post-accident income received.