OFSCDRS 1994

The applicant, a fast food worker, was injured as a pedestrian in a motor vehicle accident and received weekly income benefits.

The insurer terminated benefits after an independent medical examination suggested she could attempt a return to work.

The applicant had previously attempted to return to work but was unable to continue due to pain from her ankle and knee injuries.

The arbitrator preferred the evidence of the applicant's treating orthopaedic surgeon over the insurer's assessor, finding the applicant was substantially unable to perform the essential tasks of her employment, which required prolonged standing and repetitive squatting.

The applicant was awarded weekly income benefits for the disputed period, along with interest and arbitration expenses.

The applicant, a 22-year-old woman living at home, sought death benefits from the insurer following her mother's death in a motor vehicle accident.

The central issue was whether the applicant was 'principally dependent for financial support' on her mother under section 3(2) of the Statutory Accident Benefits Schedule.

The arbitrator found that despite the applicant's part-time employment and unawareness of investments in her name, she relied almost completely on her mother for the basic necessities of life.

The arbitrator concluded the applicant was principally dependent on her mother and ordered the insurer to pay $70,000 in death benefits.

The applicant was injured in a motor vehicle accident and applied for statutory accident benefits, specifically claiming higher transportation expenses and compensation for his wife's driving services due to his driving phobia.

The arbitrator found that 30 cents per kilometre was a reasonable rate for transportation expenses, rejecting the insurer's lower calculation based only on operating costs.

The arbitrator also accepted that the applicant suffered from a severe driving phobia caused by the accident and awarded compensation for his wife's driving services at the minimum wage rate for the hours reasonably required to attend medical appointments.

The applicant was injured in a motor vehicle accident and received weekly statutory accident benefits for 18 months before the insurer terminated them.

The applicant sought arbitration, claiming continued entitlement to weekly benefits on the basis of a substantial inability to perform his essential tasks.

The arbitrator found that the applicant's condition had improved significantly and that his pain did not substantially impair his ability to perform his essential tasks during the disputed period.

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

The applicant appealed an arbitrator's decision denying his claim for expenses after he withdrew his application for arbitration at the start of the hearing.

The applicant sought an oral rehearing to re-establish his statutory accident benefits and claim expenses.

The Director of Arbitrations held there was no jurisdiction to hear the benefits claim as it was never arbitrated.

The Director also declined to admit fresh evidence and found no reason to interfere with the arbitrator's discretionary decision to deny expenses, noting the applicant's withdrawal was capricious.

The appeal was dismissed with no expenses awarded.

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

The Insurer paid weekly income benefits at the minimum rate of $185.60 per week.

The Applicant sought the maximum rate of $600 per week, claiming additional pre-accident income from employment at a dry cleaner and real estate commissions.

The arbitrator found that the documentary evidence supporting the employment income and one of the real estate commissions was likely fabricated.

The arbitrator determined that the Applicant's pre-accident income should be averaged over 52 weeks, resulting in an entitlement to the minimum rate of $185.60 per week.

The claims for a special award and arbitration expenses were dismissed due to the fabricated evidence and the Insurer's reasonable conduct.

The applicant, a high school student, was severely injured in a motor vehicle accident and suffered significant psychological trauma.

His therapist recommended a transfer to a private boarding school to assist his recovery by providing a structured social environment.

The insurer refused to pay the tuition, arguing it was not a reasonable or necessary expense resulting from the accident.

The arbitrator found that the applicant's pre-existing psychological vulnerability made him particularly susceptible to trauma, and that the boarding school placement was a successful and reasonable rehabilitation measure.

The insurer was ordered to reimburse the tuition and boarding expenses for two years.

The appellant appealed an arbitrator's decision denying him weekly benefits and a lump sum award under the Insurance Act following a motor vehicle accident.

The appellant argued the arbitrator misapprehended the medical evidence and his ability to perform tasks, and requested a referral to the Medical and Rehabilitation Advisory Panel.

The Director of Arbitrations found no error in the arbitrator's assessment of the evidence, noting the appellant's ability to engage in activities such as cross-country skiing and municipal election campaigning.

The appeal was dismissed, but the appellant was awarded his filing fee expenses.

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

The Insurer terminated weekly income benefits on March 31, 1993.

The Applicant sought arbitration for further weekly income benefits, supplementary medical and rehabilitation expenses, and housekeeping and child care expenses.

The arbitrator found that the Applicant was not substantially unable to perform her essential tasks and dismissed the claim for further weekly income benefits.

The arbitrator awarded certain supplementary medical and rehabilitation expenses, including transportation and a club membership, but denied the claim for housekeeping and child care expenses due to insufficient evidence.

The Applicant was injured in a motor vehicle accident and received weekly income benefits until the Insurer terminated them based on an independent medical examination.

The Applicant sought reinstatement of benefits, arguing he remained unable to perform his physically demanding job as a fence installer.

The Arbitrator found the Applicant was substantially unable to return to work until June 3, 1993, and ordered benefits paid to that date.

The Arbitrator also determined that the Applicant's accrued vacation pay should be allocated over the period it was earned for the purpose of calculating his gross weekly income.

The Applicant's claim for a special award was dismissed, as the Insurer's reliance on its medical report to terminate benefits was not unreasonable.

The applicant, a 70-year-old retiree, was injured in a motor vehicle accident and suffered a compression fracture of the L4 vertebrae.

The insurer paid weekly benefits under section 13 of the Statutory Accident Benefits Schedule but terminated them on April 21, 1993, arguing the applicant was no longer substantially unable to perform his essential pre-accident tasks.

The arbitrator determined the applicant's essential tasks included personal care, limited household chores, and a daily walk.

The arbitrator found that the applicant remained substantially unable to perform these tasks until June 8, 1993, when he was discharged from a physiotherapy program having resumed about 70% of his normal daily regimes.

The applicant was awarded weekly benefits for the closed period from April 21 to June 8, 1993, plus interest and arbitration expenses.

The applicant was struck by a car while crossing the street, sustaining pelvic fractures, a closed head injury, and significant soft tissue injuries.

She received weekly income benefits until the insurer terminated them, arguing she could return to her job as a sewing machine operator.

The arbitrator found that the applicant's chronic pain prevented her from maintaining the sustained positions, speed, and dexterity required for her piecework job, entitling her to benefits under section 12(1) for the initial 156-week period.

However, the applicant failed to establish that she was continuously prevented from engaging in any occupation for which she was reasonably suited, so benefits under section 12(5)(b) were denied.

The arbitrator also ordered the insurer to reimburse the applicant for a new mattress, finding it was a reasonable expense required because of the accident to help with sleep disturbances.

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

The Applicant sought ongoing weekly income benefits, arguing he was employed at the time of the accident despite being on medical leave from his job as a courier.

The arbitrator found that the Applicant had resolved not to return to his position and had effectively ended his employment prior to the accident, meaning he did not qualify for benefits under section 12 of the Schedule.

Furthermore, based on functional capacity evaluations, the arbitrator concluded that the Applicant no longer suffered a substantial inability to perform his essential tasks after the termination date.

The claim for ongoing benefits was dismissed, but the Applicant was awarded the expenses of the arbitration.

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

A dispute arose regarding the correct calculation of his pre-accident income from self-employment.

The arbitrator found that the applicant failed to provide sufficient documentation to prove his net income exceeded the minimum threshold, entitling him only to the minimum benefit of $185.60 per week.

Consequently, the insurer was entitled to repayment of $15,951.51 in overpaid benefits, while the applicant was awarded his arbitration expenses.

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

The applicant sought arbitration to reinstate the benefits and increase the weekly rate.

The arbitrator found that the applicant had a significant pre-existing back condition (ankylosing spondylitis) which he had concealed from medical examiners.

Due to inconsistencies and false evidence regarding his post-accident employment and pre-accident income, the arbitrator concluded the applicant failed to prove a substantial inability to perform his essential tasks.

The claim for further benefits was dismissed, the weekly rate was maintained at the statutory minimum, and no costs were awarded to either party.

In a supplementary decision, the arbitrator determined two legal issues: the interest applicable to a special award and entitlement to caregiver benefits for a child en ventre sa mère at the time of the accident.

The arbitrator held that the 2 per cent compound interest under section 282(10) of the Insurance Act does not apply to the lump sum special award itself; rather, the special award bears interest under the Courts of Justice Act.

Furthermore, the arbitrator concluded that section 13(4) of the Statutory Accident Benefits Schedule requires a dependant to be born alive and residing with the insured at the time of the accident, thereby excluding a child en ventre sa mère.

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 she was unable to perform her occupation as a housecleaner due to post-traumatic fibromyalgia.

The insurer argued she was exaggerating her symptoms and could return to work.

The arbitrator preferred the evidence of the applicant's treating physicians, finding her pain genuine and her inability to work through it justified.

The arbitrator awarded ongoing weekly income benefits, interest, and expenses, but denied a special award, finding the insurer's termination was not unreasonable given the conflicting medical opinions and the applicant's exaggerated behaviours.

The applicant was injured in a motor vehicle accident and received weekly income benefits until they were terminated by the insurer in July 1991.

The applicant applied for arbitration in December 1993, more than two years after the termination of benefits.

The insurer raised a preliminary issue that the application was barred by the two-year limitation period under subsection 281(5) of the Insurance Act.

The arbitrator found that the applicant failed to adequately explain the delay and held that he was not entitled to proceed to arbitration.

The applicant was awarded his expenses for the preliminary hearing, and the insurer's request for expenses was denied.

The Applicant was injured in a motor vehicle accident and sought statutory accident benefits for transportation expenses to see doctors in Toronto after moving to London, Ontario.

The arbitrator allowed transportation expenses for visits to an orthopaedic surgeon and a neurologist, finding them reasonable.

However, transportation expenses for visits to a family doctor and a psychiatrist were limited to a local distance of 25 kilometres per visit, as the treatment was routine and local alternatives were available.

Claims for a $125 fee paid to a psychiatrist and for hydrotherapy were dismissed due to insufficient evidence.

The Applicant was awarded expenses for the arbitration.

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

The applicant sought arbitration, claiming ongoing disability due to neck, shoulder, and back pain.

The arbitrator reviewed medical evidence and surveillance videotape showing the applicant performing physical tasks without apparent difficulty.

Finding the applicant's testimony evasive and lacking objective medical corroboration, the arbitrator concluded the applicant failed to prove a substantial inability to perform the essential tasks of his pre-accident employment.

The claim for ongoing weekly benefits was dismissed.