OFSCDRS 1995

The insurer sought an order requiring the insured to attend an independent medical examination in London and a functional capacities evaluation at the Canadian Back Institute.

The arbitrator held that the insurer could choose its medical examiner, but it was unreasonable to require the insured to travel from Windsor to London for the examination.

The arbitrator also dismissed the request for a functional capacities evaluation, finding no evidence that the chosen doctor required an assessment by an undesignated health professional to assist in evaluating the insured's condition.

The applicants, a husband and wife, claimed statutory accident benefits following three motor vehicle accidents in late 1992.

The insurer terminated benefits and sought repayment, alleging the claims were fraudulent and the symptoms exaggerated.

The arbitrator found the applicants were not credible, noting significant inconsistencies in their evidence regarding their business, prior medical history, and post-accident activities.

Medical and surveillance evidence demonstrated that the husband was malingering and his psychological issues predated the accidents, while the wife had concealed her ongoing college attendance and prior accident history from her doctors.

The arbitrator dismissed the applicants' claims for ongoing weekly income benefits, housekeeping, and visitor expenses, and ordered both applicants to repay all benefits previously received, with interest, pursuant to section 27 of the Schedule.

The applicant's husband committed suicide by running a hose from the exhaust pipe into the passenger compartment of his car.

The applicant sought funeral and death benefits under the Statutory Accident Benefits Schedule.

The insurer denied the claim on the basis that the death was not an 'accident'.

The arbitrator held that while the death resulted from an 'incident' involving the use of an automobile, the term 'incident' in the definition must be restricted to the category of 'accident'.

Since the death was planned and deliberate, it was not an accident.

The application for benefits was dismissed.

The insurer appealed an arbitrator's decision awarding the surviving children of a couple killed in a motor vehicle accident $10,000 each in respect of the death of their mother, in addition to the $10,000 each already paid in respect of their father.

The insurer argued that under the Statutory Accident Benefits Schedule, a person can only be 'principally dependent for financial support' on one person at a time.

The Director of Arbitrations dismissed the appeal, finding that the wording of s. 3(2) allows a child to be a dependant of both parents, entitling them to death benefits for each.

The respondents' cross-appeal for a special award was also dismissed, as the insurer's position was based on a legitimate dispute over statutory interpretation.

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

The parties subsequently met and the applicant signed a release in exchange for a $2,000 lump sum payment.

The applicant later sought to arbitrate her entitlement to further benefits, alleging she did not sign the release, or alternatively, that the settlement was vitiated by mistake, duress, or inequality of bargaining power.

The arbitrator found that the applicant did sign the release, relying on expert handwriting evidence, and that there were no vitiating factors.

The arbitration was deemed frivolous and an abuse of process, and the applicant was ordered to pay $1,000 to the insurer.

The applicant was injured in a rear-end motor vehicle accident and subsequently developed chronic pain syndrome and reactive depression.

The insurer terminated her weekly income benefits after she failed to complete a functional restoration program, arguing she was physically capable of working and her failure to cooperate was wilful.

The arbitrator found that the applicant's failure to participate in therapy was not wilful but rather a symptom of her accident-induced depression and pain.

Consequently, the applicant was entitled to weekly income benefits under section 12(1) of the Schedule until the 156-week mark, and under section 12(5)(b) until September 30, 1995, by which time she had sufficiently recovered psychologically to participate in rehabilitation.

The claim for a special award was dismissed as the insurer's reliance on medical opinions to terminate benefits was not unreasonable.

The applicant was injured in a motor vehicle accident in January 1991 and received weekly income benefits until January 1994.

She applied for arbitration to reinstate her benefits, claiming ongoing disability from headaches, neck pain, and psychological issues.

The arbitrator found that while the applicant had ongoing symptoms, surveillance video and an independent medical examination demonstrated she had a significantly higher level of function than claimed.

The arbitrator concluded that unrelated stressors, rather than the minor accident, were the significant contributing factors to any ongoing disability after August 1994.

The applicant was awarded weekly income benefits from January 16, 1994, to August 19, 1994.

The arbitrator declined to rule on the insurer's request to deduct Canada Pension Plan disability benefits, finding the issue of the benefit rate was not properly before the tribunal.

The Arbitrator issued a correction to a previous decision dated June 13, 1995.

A typographical error citing Section 227(5)(1) of the Act was deleted and replaced with the correct citation, Section 227(5).

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

The parties attended mediation and signed a settlement agreement for $16,900.

The Applicant later sought to arbitrate the claims, arguing he was confused during mediation and that the Insurer failed to pay outstanding physiotherapy expenses.

The Arbitrator found that the Applicant understood the settlement, signed a release, and failed to rescind it within the two-day cooling-off period.

The preliminary issue was resolved in favour of the Insurer, barring the Applicant from proceeding to arbitration.

The Applicant's request for expenses was denied as the application was deemed frivolous.

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

After a partially successful mediation, the applicant commenced a court action against the insurer.

Subsequently, the applicant sought to arbitrate the issue of whether she was an 'insured person' under the policy.

The insurer argued the arbitration should be stayed to avoid a multiplicity of proceedings.

The arbitrator dismissed the arbitration application, finding that the court action began first, was more comprehensive, and would necessarily decide the 'insured person' issue.

The applicant was awarded her expenses for the arbitration as the application was not frivolous.

The applicant was injured in a motor vehicle accident and applied for weekly income benefits, claiming he had a legitimate offer of employment as a cook at the time of the accident.

The arbitrator found the applicant's evidence and that of his witnesses regarding the job offer to be untrustworthy and contradictory.

The arbitrator concluded that the applicant did not have a genuine offer of employment and dismissed the claim for income benefits.

Finding that the applicant advanced a dishonest claim and abused the arbitration process, the arbitrator denied the applicant's hearing expenses and ordered him to pay a $2,000 assessment to the insurer.

The applicant sought statutory accident benefits for herself as a common-law spouse and for her two children as dependants following the death of her former husband in a motor vehicle accident.

The insurer denied the claims.

The arbitrator found that the applicant and the deceased had divorced and were not cohabiting in an integrated spousal relationship at the time of the accident.

The arbitrator also found that the children were not principally dependent for financial support on the deceased.

The claims for death benefits were dismissed.

In a supplementary decision, the Arbitrator calculated the exact amount of weekly income benefits owing to the applicant following a motor vehicle accident.

The parties agreed on the base figures but disputed the calculation of the applicant's average gross weekly income from her business.

The Arbitrator determined the net business income for the 52 weeks preceding the accident, calculated the gross weekly income, and applied the statutory formula.

After deducting amounts paid by the insurer and post-accident earnings, the insurer was ordered to pay $27,460.78 plus interest.

The Applicant was injured in a motor vehicle accident when struck as a pedestrian.

She received weekly income benefits until July 27, 1993, and subsequently applied for arbitration claiming ongoing entitlement and payment for a medical report.

The arbitrator found that the Applicant was substantially able to perform the essential tasks of her pre-accident job as an industrial sewing machine operator, preferring the evidence of orthopaedic surgeons over her pain management physician.

The claim for the medical report was also dismissed as it was deemed a medicolegal report rather than a certificate under the Schedule.

The Applicant was awarded her arbitration expenses.

The applicant was injured in two motor vehicle accidents 26 days apart.

After her WCB benefits for the first accident were terminated, she applied to her auto insurer for statutory accident benefits relating to the second accident.

The insurer denied the claim, arguing she was no longer disabled or that any disability stemmed from the first accident.

The arbitrator found that the second accident significantly exacerbated her injuries and that she remained substantially unable to perform the essential tasks of her pre-accident employment.

The applicant was awarded weekly income benefits and rehabilitation expenses for a work re-activation program, but her claims for chiropractic expenses and a special award were dismissed.

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

The insurer claimed the parties reached a final settlement of the applicant's entitlement to weekly income benefits for $8,000, and relied on a signed release.

The applicant argued the payment was only an advance on one year of benefits.

The arbitrator found that there was no meeting of the minds between the parties regarding the nature of the payment and the release was vitiated by mistake.

The preliminary issue was resolved in favour of the applicant, allowing her to proceed to arbitration on her claim for weekly income benefits.

The Applicant was injured when he rode his bicycle into a pothole after being distracted by the sound of a car engine starting.

He applied for statutory accident benefits.

The preliminary issue was whether the incident constituted an 'accident' under section 2 of the Statutory Accident Benefits Schedule.

The Arbitrator found that the starting of a car engine constitutes the 'use or operation' of an automobile, and that this use indirectly caused the Applicant's injuries by distracting him and causing him to hit the pothole.

The Arbitrator concluded the Applicant was injured as a result of an accident.

The applicant was injured in a motor vehicle accident and received weekly income benefits for 156 weeks.

The insurer terminated benefits thereafter.

The applicant sought ongoing weekly income benefits under section 12(5)(b) of the Statutory Accident Benefits Schedule, as well as rehabilitation and occupational training.

The arbitrator found that the applicant's physical restrictions prevented him from engaging in any occupation for which he was reasonably suited by education, training, or experience, and ordered ongoing weekly income benefits.

The arbitrator also ordered the insurer to pay for a comprehensive vocational rehabilitation assessment.

Finding that the insurer acted unreasonably in terminating benefits despite medical and functional capacity reports supporting the applicant's disability, the arbitrator ordered a special award of 35% of the outstanding weekly income benefits.

The applicant was injured in a motor vehicle accident and received statutory accident benefits as an unemployed person.

He subsequently claimed he had a valid offer of employment at the time of the accident and should receive higher benefits under section 12 of the Statutory Accident Benefits Schedule.

The insurer terminated his benefits entirely on June 17, 1994, arguing he was no longer substantially unable to perform his essential tasks.

The arbitrator found that the applicant did not have a legitimate pre-accident offer of employment.

Relying on medical reports and surveillance video showing the applicant driving and assisting passengers, the arbitrator concluded the applicant could perform his essential tasks and upheld the termination of benefits.

The arbitrator also found the applicant's subsequent shoulder dislocation was not caused by the accident.

The applicant was awarded his arbitration expenses.

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

The insurer terminated benefits based on surveillance video allegedly showing the applicant working.

The applicant disputed his identity in the videos, prompting a preliminary issue hearing.

After reviewing the video evidence, photographs, and witness testimony, the arbitrator concluded the applicant was indeed the individual depicted in the September 15, 1993 surveillance tape.

The applicant's request for hearing expenses was denied because his late admissions unnecessarily prolonged the proceedings.