OFSCDRS 1995

The applicant sought to enforce a settlement agreement regarding statutory accident benefits after the insurer rescinded its offer.

The insurer argued the arbitrator lacked jurisdiction to determine if a settlement existed.

The arbitrator held that she had jurisdiction by necessary implication to determine if a settlement was reached.

However, because the insurer had not delivered the written notice required by the Settlement Regulation (O. Reg. 780/93) before the settlement was entered into, no enforceable settlement was achieved.

The applicant was awarded expenses for the preliminary hearing.

The appellant was involved in two motor vehicle accidents and claimed weekly income benefits and supplementary medical benefits.

The arbitrator terminated weekly income benefits as of October 1, 1992, and denied the medical benefits.

Both the appellant and one of the insurers appealed the decision.

The Director's Delegate dismissed the appeals, finding that the arbitrator's conclusions were supported by the evidence, including the finding that the appellant's fibromyalgia was not significantly contributed to by the accidents.

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

He applied for arbitration seeking ongoing weekly income benefits and supplementary medical and rehabilitation expenses.

The arbitrator found that the applicant was reasonably suited for teaching and thus not entitled to ongoing income benefits under section 12(5)(b), except for a six-month recovery period following back surgery.

The arbitrator also awarded limited case management services and a six-month diet program, but denied a special award, finding the insurer had not unreasonably withheld payments.

The applicant was severely injured in a 1991 motor vehicle accident and received statutory accident benefits for 156 weeks.

The insurer terminated benefits, arguing she no longer met the test of being continuously prevented from engaging in substantially all of her normal activities.

The arbitrator found that while her physical injuries had healed, she continued to suffer from cognitive deficiencies, dissociative states, and chronic fatigue that severely limited her ability to function independently, maintain her home, or engage in social and parental activities.

The arbitrator concluded she met the post-156 week test and ordered the insurer to pay ongoing weekly and child care benefits.

The Arbitrator issued a correction to a previous decision dated November 24, 1995.

The correction amended references to a cited case, Polus, to correctly identify the arbitrator as Arbitrator Seife instead of Arbitrator Palmer, and to change the corresponding pronouns from female to male.

The appellant appealed an arbitration decision that terminated her weekly income benefits and ordered her to repay an overpayment.

The appellant failed to file materials or written submissions for the appeal, which proceeded on the record.

The Director's Delegate found no merit in the appeal, confirming the arbitrator's decision.

The insurer was awarded $500 under the Insurance Act on the basis that the appeal was frivolous, vexatious, or an abuse of process, as the appellant raised no serious question and failed to pursue the appeal beyond filing the notice.

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

The Insurer terminated weekly income benefits, and the Applicant applied for arbitration.

The Insurer argued that the parties had entered into a binding settlement prior to the arbitration hearing.

The Arbitrator held that under section 9.1 of the Settlement Regulation, the delivery of a written notice by the insurer is a pre-condition to entering into a settlement.

Because the cooling-off period had not commenced or expired before the Applicant rescinded the agreement, no binding settlement was entered into.

The Applicant was permitted to proceed with the arbitration.

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 but failed to attend a scheduled independent medical examination (IME).

The insurer brought a motion to stay the arbitration hearing.

The arbitrator held that under sections 23(2) and 25 of the Statutory Accident Benefits Schedule, an applicant cannot proceed with the dispute resolution process unless they make themselves reasonably available for a medical examination.

The motion was granted, and the applicant was precluded from proceeding with the arbitration until she makes herself available for the IME.

The Applicant was struck by a car and claimed statutory accident benefits, including weekly income benefits and supplementary medical and rehabilitation benefits.

The Insurer terminated weekly income benefits, arguing the Applicant could return to work as a car salesman.

The Applicant claimed ongoing disability due to a head injury causing cognitive and psychological impairments.

The Arbitrator found that the Applicant's ongoing impairments were rooted in a severe pre-existing personality disorder and not the accident.

Claims for weekly income benefits and case management services were dismissed.

However, the Arbitrator awarded certain transportation expenses and a special award of $100 because the Insurer unreasonably withheld payment of transportation expenses pending the dispute.

The applicant was seriously injured in a motor vehicle accident while a passenger in a vehicle insured by State Farm.

She claimed statutory accident benefits.

The issue was whether she was the spouse of the owner of another vehicle, insured by Allstate, at the time of the accident.

The arbitrator found that the applicant and the Allstate insured, who were the natural parents of a child and had resumed a relationship including weekend cohabitation prior to the accident, met the extended definition of 'spouse' under the Insurance Act.

Consequently, Allstate was held liable to pay the applicant's accident benefits.

The applicant sought the cost of a Vigano couch or a chair as a supplementary medical and rehabilitation benefit following a motor vehicle accident.

The insurer denied the claim and sought repayment of funds previously advanced for an orthopaedic mattress, alleging fraud.

The arbitrator dismissed the applicant's claim, finding the specific couch ordered was not firm as prescribed by his doctor.

The arbitrator ordered the applicant to repay $388.48 to the insurer, as he had fraudulently pocketed the difference between the funds advanced for a queen-sized mattress and the cheaper twin beds he actually purchased.

The applicant was denied his expenses for the arbitration.

The applicant applied for statutory accident benefits from two insurers following a motor vehicle accident.

After mediation failed, the applicant applied for arbitration but subsequently failed to provide required medical and financial documentation, lost contact with his representative, and did not attend the hearing.

The arbitrator dismissed the claims for failure to prove entitlement and found the applicant's conduct constituted an abuse of process.

The applicant was ordered to pay $2,000 to each insurer for their assessment fees pursuant to section 282(11.2) of the Insurance Act.

The Applicant was injured in a motor vehicle accident and claimed weekly income benefits under section 12 of the Statutory Accident Benefits Schedule, arguing she was employed as a nurse at the time of the accident.

The Insurer argued she was unemployed and entitled to benefits under section 13.

The Applicant worked on a casual, on-call basis for two nursing agencies and was not on an assignment when the accident occurred.

The arbitrator found that the Applicant was not employed at the time of the accident, as she had no guarantee of work, was not receiving salary, and had not worked the required 180 days in the preceding 12 months to qualify under section 12(3).

Therefore, the Applicant was entitled to benefits under section 13.

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

A priority dispute arose between the insurer of the vehicle she was in (Simcoe & Erie) and the insurer of her sister and brother-in-law's vehicle (Farmers').

The issue was whether the applicant was a dependant of her sister and brother-in-law, with whom she lived.

The arbitrator found that the applicant provided extensive childcare and household services in exchange for room and board, and also earned part-time income.

Relying on expert economic evidence, the arbitrator concluded that the value of the applicant's services and income significantly exceeded the value of the room and board she received.

Therefore, she was not principally dependent on her relatives, and Simcoe & Erie was liable to pay her benefits.

The applicant sought statutory accident benefits following a motor vehicle accident.

The insurer terminated weekly benefits and sought repayment, arguing the applicant drove without the owner's consent.

The arbitrator found the applicant was not entitled to further weekly income or care benefits as he was unemployed and able to perform his essential tasks.

However, the insurer's claim for repayment was dismissed because it failed to prove the applicant knew or ought to have known he was driving without consent.

The applicant was awarded his filing fee as expenses.

The insurer appealed a pre-hearing arbitrator's order requiring it to produce all internal memoranda from the date of the accident to the date the applicants requested mediation.

The applicants sought the documents to support a claim for a special award under s. 282(10) of the Insurance Act.

The Director's Delegate allowed the appeal and revoked the production order, finding that a bald assertion that benefits were unreasonably withheld is not a sufficient basis for ordering the production of the insurer's entire file.

A special award is a statutory direction to the arbitrator, not a separate claim that creates an independent basis for production.

The applicant was injured in a motor vehicle accident and applied for statutory accident benefits, including weekly income benefits and transportation expenses.

The insurer denied the claims, arguing the applicant was not substantially disabled from his work as a commercial cleaner and alleging a material misrepresentation or change in risk regarding the insured vehicle.

The arbitrator found the applicant was substantially unable to perform his essential tasks for nine weeks and awarded minimum weekly income benefits due to insufficient financial evidence.

The arbitrator also awarded transportation expenses for chiropractic treatments and a 40% special award against the insurer for unreasonably withholding those expenses.

The insurer failed to prove a material misrepresentation or intentional failure to notify of a change in risk that would exclude the applicant from receiving benefits.

The Applicant was found unconscious and severely injured on a sidewalk and claimed he was struck by a motor vehicle.

The Insurer denied his claim for statutory accident benefits, arguing his injuries resulted from a fall, not a motor vehicle accident.

The arbitrator found on a balance of probabilities that the Applicant was injured in an 'accident' as defined in the Schedule, likely a hit-and-run.

The Applicant was awarded weekly income benefits of $61.63 per week for a specified period, supplementary medical and rehabilitation benefits for physiotherapy and psychological services, plus interest and arbitration expenses.

The applicant was injured in a motor vehicle accident and claimed statutory accident benefits, including weekly income benefits and housekeeping expenses.

The insurer terminated benefits, arguing the applicant was misrepresenting her symptoms and was capable of working.

The arbitrator found that the applicant suffered from post-traumatic stress disorder and chronic pain syndrome resulting from the accident, which substantially disabled her from performing the essential tasks of her employment in her husband's business until August 15, 1994.

The arbitrator awarded weekly income benefits up to that date, as well as housekeeping expenses, but denied the claim for holiday expenses.

The Arbitrator issued a correction to a previous decision regarding statutory accident benefits.

The original decision incorrectly calculated the deduction of Canada Pension Plan benefits from the applicant's weekly income benefit.

The correction clarified that the deduction should be made from 80% of the applicant's gross weekly income, resulting in an increased weekly benefit amount and a higher total underpayment owed by the insurer.

The insurer was ordered to pay the corrected underpayment amount of $5,160.11 plus interest.