OFSCDRS 1994

The applicant was involved in two motor vehicle accidents in October 1990 and received weekly income benefits until April 1991.

He applied for arbitration after the insurer terminated his benefits, claiming he remained substantially unable to perform the essential tasks of his pre-accident employment as a security guard due to chronic pain.

The arbitrator found that the applicant's job was not physically demanding and that the medical evidence, including surveillance video, did not support a finding of substantial inability to work.

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

A treatment provider commenced an arbitration proceeding against an insurer in the name of the insured person, seeking payment of $260 for case management services.

The treatment provider relied on an authorization signed by the insured person.

The arbitrator held that under section 281(1) of the Insurance Act, only the insured person has the statutory right to commence an arbitration, and this right cannot be assigned to a treatment provider.

In the alternative, the arbitrator found that the case management services, which primarily involved attempts to secure benefits, were not rehabilitation services required as a result of the accident.

The application was dismissed and no expenses were awarded.

The applicants, two brothers, were injured in a motor vehicle accident and sought weekly income benefits from their insurer.

The insurer terminated benefits in the summer of 1992.

Following an arbitration hearing, the arbitrator determined the applicants' pre-accident weekly incomes and calculated their respective benefit amounts.

Based on medical and psychological evidence, the arbitrator found that one applicant was disabled from his job as a bodyshop helper until December 30, 1992, and the other was disabled from his job as a cleaner until April 30, 1993.

Claims for repayment by the insurer and a special award by the applicants were dismissed due to a lack of evidence.

The applicants were awarded their 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 ongoing benefits, claiming a substantial inability to perform his essential tasks.

The arbitrator found that the applicant exaggerated his injuries and that surveillance evidence contradicted his claims of disability.

Relying on the insurer's orthopaedic expert, the arbitrator concluded the applicant's physical injuries resolved shortly after the accident and awarded benefits only for an additional brief period up to October 3, 1990.

The applicant was injured in a minor rear-end motor vehicle accident and claimed weekly accident benefits as a homemaker.

The insurer paid benefits until January 3, 1991, and then terminated them based on surveillance and an adjuster's lay observations, despite medical evidence supporting ongoing disability.

The arbitrator found that the applicant's part-time sales work from home did not disqualify her from claiming homemaker benefits under section 13 of the Statutory Accident Benefits Schedule.

The arbitrator concluded that the applicant suffered a somatoform pain disorder triggered by the accident and remained substantially unable to perform her essential homemaking tasks until December 1, 1991.

The arbitrator awarded weekly benefits of $285 for the disputed period and ordered a $4,000 special award against the insurer for unreasonably terminating and withholding benefits without medical evidence.

The applicant was injured in a motor vehicle accident and received statutory accident benefits until the insurer terminated them, claiming she no longer met the eligibility test.

The applicant sought arbitration for ongoing weekly benefits and supplementary medical and rehabilitation benefits for chiropractic care.

The arbitrator found that while the applicant continued to experience discomfort and a minor disability, she had not established a substantial inability to perform her essential tasks.

The arbitrator also concluded that prolonged, open-ended chiropractic treatments were not reasonable or necessary.

The claims for ongoing benefits were dismissed, but the applicant was awarded her arbitration expenses as the application was not frivolous.

In a supplementary arbitration decision, the applicant sought statutory accident benefits for child care and housekeeping services provided by her mother, as well as expenses for her husband's lost income while attending the hearing.

The arbitrator found that the applicant was not entitled to benefits for the period prior to her back surgery, but awarded $1,344.00 for heavy housekeeping assistance required post-surgery.

The claim for the husband's lost income as an expense was denied.

The applicant was injured in a motor vehicle accident and received weekly benefits until they were terminated on May 31, 1991.

She applied for arbitration on September 13, 1993.

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

The arbitrator found that the insurer's letter of May 6, 1991, clearly and unequivocally communicated the refusal to pay benefits after May 31, 1991.

The insurer's subsequent conduct in reconsidering the claim did not estop it from relying on the limitation period.

The application for arbitration was dismissed as statute-barred.

The applicant was injured in a motor vehicle accident and received weekly accident benefits until the insurer terminated them, arguing she was capable of returning to work.

The applicant applied for arbitration, claiming ongoing disability from her two pre-accident jobs as a housekeeping aid and a chiropractic assistant.

The arbitrator found that while the applicant could likely perform the chiropractic assistant role, she remained substantially disabled from the physical demands of the housekeeping job due to accident-related lower back pain.

The arbitrator ordered the reinstatement of weekly benefits, along with interest on overdue payments.

Additionally, the arbitrator granted a $2,000 special award against the insurer for unreasonably delaying initial benefit payments without providing required notice, and awarded the applicant her arbitration expenses.

The applicant, a student, was injured in a motor vehicle accident and claimed weekly benefits for substantial inability to perform her essential tasks.

The insurer denied benefits on the basis that she continued to attend school and complete her term.

The arbitrator found that the applicant suffered a substantial inability to perform her essential tasks until December 1992, but section 16(3) of the Schedule relieved the insurer from paying benefits while she attended school.

The arbitrator awarded weekly benefits for the period after the school term ended, and granted a $1,000 special award against the insurer for unreasonably denying benefits without conducting a proper medical inquiry.

The applicant, a 15-year-old high school student, was seriously injured in a motor vehicle accident.

She received weekly income benefits until January 1993.

The applicant claimed she suffered a brain injury in the accident that caused severe psychiatric and behavioural problems, entitling her to further benefits.

The insurer argued her psychiatric difficulties were not caused by the accident but were the result of a pre-existing condition, likely bipolar disorder.

The arbitrator found that the applicant sustained at most a mild head injury and that the accident was not a significant contributing factor to her subsequent severe mental illness.

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

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

The Insurer terminated benefits, arguing the Applicant was not employed or on a temporary lay-off at the time of the accident.

The arbitrator found that the Applicant, who had been laid off due to a shortage of work but maintained a reasonable expectation of recall, was on a temporary lay-off at the time of the accident.

The Applicant was deemed eligible for benefits and awarded arbitration expenses.

The applicant was injured in a motor vehicle accident and claimed statutory accident benefits for university residence fees, arguing her injuries prevented her from commuting from home as originally planned.

The insurer paid for the first two years but disputed entitlement for subsequent years, alternatively arguing for a deduction of hypothetical commuting and meal costs.

The arbitrator found that the applicant's physical and psychological injuries, including whiplash and post-traumatic stress disorder, rendered her unable to commute daily.

The residence fees were deemed a reasonable rehabilitation expense under section 6 of the Statutory Accident Benefits Schedule.

The arbitrator also rejected the insurer's request to deduct hypothetical commuting costs, finding them speculative.

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

The insurer terminated the benefits on the basis that the applicant was capable of performing the essential tasks of his pre-accident occupation.

The applicant sought arbitration to reinstate benefits and increase the weekly quantum, claiming he was an employee earning a higher wage.

The arbitrator found the applicant's evidence regarding his employment and income lacked credibility, determining he was a partner in a business that lost money, entitling him only to the minimum weekly benefit.

The arbitrator also found the applicant failed to prove he suffered a substantial inability to perform his essential tasks during the disputed period.

The application was dismissed, the applicant was ordered to repay the overpayment, and his claim for expenses was denied.

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

The Insurer required her to attend a multi-disciplinary assessment at a rehabilitation centre under section 23(2) of the No-Fault Benefits Schedule.

The Applicant refused on the basis that the assessment would not be conducted by a qualified medical practitioner, psychological advisor, or chiropractor as required by the section.

The Arbitrator held that the Applicant was not required to attend the assessment, as section 23(2) explicitly requires the examination to be conducted by a designated health practitioner, and the proposed assessment did not meet this fundamental requirement.

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

A dispute arose regarding the calculation of his self-employment income, specifically whether reduced business expenses constituted 'ceasing expenses' under section 12(7)3. of the No-Fault Benefits Schedule, and whether post-accident income should be deducted net of expenses under section 15.

The arbitrator held that a significant reduction in an expense can be treated as a ceasing expense.

Furthermore, post-accident income under section 15 must be calculated net of expenses incurred to generate it.

The arbitrator also ordered a special award of $350 against the insurer for unreasonably delaying the reinstatement of disability benefits after the applicant's unsuccessful attempt to return to work.

The insurer brought a preliminary motion to dismiss the arbitration because the applicant failed to comply with a prior order requiring him to withdraw his related court action forthwith.

The applicant's counsel had sought the insurer's consent to dismiss the action without costs, which the insurer refused.

The arbitrator found that the applicant's failure to withdraw the action was based on a misunderstanding of the order rather than tactical reasons.

The motion to dismiss the arbitration was denied, on the condition that the applicant immediately bring a motion to dismiss the court action.

The applicant was injured on a transit bus and received weekly income benefits until they were terminated.

She applied for arbitration to reinstate the benefits, claiming a substantial inability to perform the essential tasks of her employment as a ceramic factory worker.

The arbitrator found the applicant's testimony regarding her pain and inability to work lacked credibility, preferring the objective medical evidence of orthopaedic specialists and surveillance footage showing her performing physical tasks without apparent difficulty.

The application for further weekly income benefits was dismissed, though the applicant was awarded her arbitration expenses.

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

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

The arbitrator found that the Applicant's physical injuries had largely resolved, but she continued to suffer a substantial inability to perform the essential tasks of her occupation due to psychological injuries until March 24, 1993.

The Applicant was awarded weekly income benefits up to that date, as well as supplementary medical and rehabilitation benefits for her residual psychological injuries.

The Insurer was entitled to repayment of weekly income benefits paid after March 24, 1993.