OFSCDRS 1994

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

The parties attended mediation, where the insurer claimed a settlement was reached, but the applicant later denied it and sought arbitration.

The arbitrator found that the applicant, represented by counsel, had fully understood and agreed to the settlement terms at mediation.

The arbitrator concluded that the applicant was merely having second thoughts and held that a binding settlement had been reached, precluding the applicant from proceeding to arbitration.

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 an ongoing inability to perform her essential tasks as a Becker's store manager due to chronic pain and psychological factors.

The arbitrator found that the applicant's job was physically demanding and that she remained substantially unable to perform its essential tasks.

The arbitrator rejected the insurer's arguments that the applicant's disability was solely due to unrelated personal tragedies or pregnancy, and ordered the insurer to pay ongoing weekly income benefits, interest, and arbitration expenses.

The applicant was injured in a motor vehicle accident and claimed weekly income benefits based on an alleged pre-accident job offer.

At a preliminary hearing, the applicant argued that the insurer was precluded from contesting the legitimacy of the job offer because the issue had been settled at a prior mediation.

The arbitrator found that the mediation resulted in a procedural agreement to investigate the claim further and pay a temporary amount, rather than a binding settlement conceding the legitimacy of the job offer.

The insurer was therefore not precluded from contesting the issue.

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

The applicant applied for arbitration to determine his ongoing entitlement to benefits and sought an order reinstating them at the original quantum.

At a preliminary hearing, the applicant sought to exclude the insurer's claim for repayment of alleged overpayments made prior to the termination date.

The arbitrator held that the insurer's claim for repayment consequentially flowed from the applicant's claim for a specific quantum of benefits, and therefore the repayment issue would be included in the arbitration hearing.

The applicant sustained a catastrophic brain injury in a motor vehicle accident and applied for statutory accident benefits.

The arbitrator held that the applicant was not entitled to care benefits in excess of the $3,000 monthly limit under section 7 of the Schedule, as the services provided by his family were 'care' rather than 'nursing' services.

However, the arbitrator found that the applicant's current inaccessible apartment was impeding his rehabilitation and ordered the insurer to provide rehabilitation benefits for accommodation with specific accessibility features, noting that purchasing and renovating a house was a reasonable option under section 6.

The arbitrator also granted a special award of $3,000 due to the insurer's unreasonable delay in paying certain medical and rehabilitation benefits.

The applicant was injured in a motor vehicle accident and applied for statutory accident benefits more than two years later.

The insurer denied the claim due to the delay.

The applicant argued the insurer was estopped from relying on the limitation period or had waived it.

The arbitrator found no estoppel or waiver, and held that the failure to submit the application within two years invalidated the claim, preventing the applicant from proceeding to arbitration.

The applicant was awarded expenses for the preliminary hearing.

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

A dispute over the amount of weekly income benefits went to mediation, where the Insurer claimed a settlement of $300 per week was reached.

The Applicant later applied for arbitration, arguing mediation had failed.

On a preliminary issue, the arbitrator found that the parties had indeed settled the issue at mediation, as evidenced by the mediator's report and the parties' subsequent conduct.

Consequently, the Applicant was precluded from referring the matter to arbitration under section 281(2) of the Insurance Act.

The arbitrator declined to award expenses to either party.

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

The insurer terminated weekly income benefits, and the applicant sought arbitration for ongoing income benefits, chiropractic expenses, and transportation expenses.

The arbitrator found that the applicant, who had a pre-existing back condition, was capable of returning to his modified duties as a mail service courier by October 1993.

The arbitrator also concluded that ongoing daily chiropractic treatments two and a half years post-accident were no longer reasonable or necessary.

The applicant's claims for ongoing benefits were dismissed, and he was ordered to repay 14 weeks of income benefits to the insurer, as he had received overlapping disability benefits from another source.

The applicant was awarded the expenses of the arbitration.

The Applicant was injured in a motor vehicle accident and sought weekly benefits and child care benefits under the Statutory Accident Benefits Schedule.

The Insurer terminated benefits, and the parties proceeded to arbitration.

The arbitrator found that while the Applicant suffered pain and had to modify her activities, she was not substantially unable to perform her essential tasks as a homemaker.

The claim for further weekly benefits was dismissed, though the Applicant was awarded her expenses for the arbitration.

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

The insurer subsequently suspended benefits, claiming the applicant had overstated his pre-accident income and understated his post-accident income, resulting in an overpayment.

The arbitrator determined the appropriate calculation of the self-employed applicant's pre-accident and post-accident income, preferring bank deposit records over GST returns.

The arbitrator concluded there was no overpayment and ordered the insurer to pay an additional $4,321.51 in weekly income benefits plus interest.

The applicant applied for arbitration on behalf of his granddaughter, claiming death benefits following the death of her father in a motor vehicle accident.

The insurer denied the claim on the basis that the child's mother was a separated common-law spouse and not a 'spouse at the time of the accident'.

The arbitrator held that the child was a dependant under the Schedule because she was principally dependent on the deceased's spouse, regardless of whether the spouse qualified for a spousal death benefit.

The arbitrator awarded $35,000 in death benefits to the child, finding that denying benefits to children of unmarried parents would be unfair and contrary to the Children's Law Reform Act.

Wellington Insurance Company appealed a preliminary arbitral order finding it responsible for paying statutory accident benefits to the Chapmans.

Shortly before the scheduled oral submissions, Wellington purported to unilaterally withdraw its appeal.

Allstate objected and sought an order for repayment of benefits and costs, while the Chapmans sought an interim order for continued benefits.

The Director of Arbitrations held that a tribunal has the inherent power to control its own process and is not bound to accept a unilateral withdrawal if it prejudices other parties.

However, since the underlying entitlement to benefits was now before the courts, there was no prejudice in allowing the withdrawal.

The Director also found no statutory authority to award expenses to Allstate from Wellington.

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 from the insurer.

The insurer terminated benefits based on an independent medical examination which concluded the applicant was fit to return to work.

The applicant sought ongoing benefits, while the insurer sought repayment of an overpayment resulting from erroneous income information.

The arbitrator dismissed the claim for ongoing benefits, finding the applicant was no longer substantially disabled.

The arbitrator ordered the applicant to repay the $560 overpayment, noting his failure to provide requested financial documentation.

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

After mediation failed, he commenced a court action against the insurer for the benefits.

He subsequently applied for arbitration at the Ontario Insurance Commission seeking interest, a special award, and expenses.

The arbitrator held that because the applicant had elected to proceed in court for the substantive benefits, the arbitrator had no jurisdiction to hear the claims for a special award and interest, as these are dependent on an award of benefits.

The application was dismissed.

The applicants, who were injured in motor vehicle accidents, applied for arbitration regarding statutory accident benefits.

After multiple adjournments and failing to comply with production orders, the applicants sought to withdraw their applications to proceed with a court action.

The insurer opposed the withdrawal and sought expenses, arguing the withdrawal was an abuse of process.

The arbitrator allowed the withdrawal, finding no rule preventing it before the hearing commenced.

However, the arbitrator found the applicants' conduct constituted an abuse of process and ordered each applicant to pay $1,000 in expenses to the insurer.

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

The applicant applied for arbitration but failed to appear at the hearing, subsequently withdrawing her claim.

The insurer sought a dismissal of the applicant's claims, a determination of its own claims for repayment, and an assessment of costs.

The arbitrator held that the applicant's claims were not dismissed and the insurer's claims for repayment could not be determined independently of the applicant's claims.

However, the arbitrator awarded $1,000 to the insurer under section 282(11.2) of the Insurance Act, finding that the applicant's conduct amounted to an abuse of process.

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

The parties mediated the issue of entitlement to benefits but not the amount.

At a pre-hearing discussion for arbitration, the Insurer sought to add the amount of benefits as an issue.

The arbitrator held that the amount of benefits could not be raised because it had not been mediated and did not reasonably and consequentially flow from the issue of entitlement.

The applicant was injured in a motor vehicle accident in November 1991 and received statutory accident benefits until July 1992.

She applied for arbitration seeking ongoing weekly income benefits and housekeeping expenses, claiming she was substantially unable to perform her essential tasks.

The arbitrator found that the applicant suffered from chronic pain syndrome resulting from a prior 1989 accident, and that the 1991 accident only caused a minor exacerbation that had resolved by July 1992.

The claims for ongoing weekly income benefits and housekeeping expenses were dismissed, as the ongoing symptoms were not causally connected to the 1991 accident.

The applicant was awarded her arbitration expenses.

The applicant sought an adjournment of his arbitration hearing regarding weekly benefits.

The applicant and his newly retained counsel had not prepared for the hearing and requested a three-month adjournment.

The arbitrator denied the request, noting the lack of preparation over the 11 months since the application was filed and the failure to show extenuating circumstances.

After the adjournment was denied, the applicant's counsel withdrew, and the unrepresented applicant declined to present evidence.

The arbitrator dismissed the applicant's claim for weekly benefits due to a lack of evidence, but also declined to hear the insurer's claim for repayment of overpaid benefits, directing the insurer to pursue that remedy in court.