OFSCDRS 1995

The applicant was injured in a motor vehicle accident and received statutory accident benefits, including weekly income and supplementary medical benefits, until April 1994.

She applied for arbitration to reinstate these benefits, claiming she suffered from chronic pain that prevented her from returning to her pre-accident job as a security guard.

The arbitrator reviewed medical evidence and video surveillance showing the applicant performing various physical activities, including shopping and shoveling snow.

The arbitrator preferred the evidence of the insurer's rehabilitation specialist and concluded the applicant no longer suffered a substantial inability to perform the essential tasks of her employment.

The claims for ongoing benefits were dismissed, though the applicant was awarded her arbitration expenses.

The applicants sought death benefits following the death of the insured in a motor vehicle accident.

The insurer denied the claim on the basis that the applicant and the insured had not cohabited continuously for three years and were therefore not spouses under the Insurance Act.

The arbitrator found that despite maintaining separate residences for a portion of the three-year period, the parties lived together as a family unit, shared domestic chores, and were financially interdependent.

The arbitrator concluded the parties were spouses and awarded death benefits to the applicant and her daughter.

The applicant, a physiotherapist, sought statutory accident benefits including weekly income benefits and physiotherapy expenses following a motor vehicle accident.

The applicant had opened his own physiotherapy clinic shortly after the accident and billed the insurer for self-administered treatments.

The arbitrator found the applicant's evidence regarding his disability and need for treatment to be unreliable and entirely without merit, noting an irreconcilable conflict of interest in his self-treatment and billing practices.

The claims were dismissed, and the applicant was ordered to reimburse the insurer's $1,000 assessment fee due to the frivolous and vexatious nature of the arbitration.

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

He subsequently returned to work intermittently, earning substantial post-accident income.

The insurer argued that 80% of all post-accident income should be deducted from benefits on a 'carry forward' basis, applying excess earnings against future benefits.

The arbitrator rejected this approach, finding it would act as a disincentive to rehabilitation and returning to work.

Instead, the arbitrator held that post-accident income must be matched directly to the specific weekly income benefit payable in the week it was earned, with no carry forward of any excess.

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

He applied for and received statutory accident benefits from Wellington, his father's insurer, claiming to be a dependant.

Wellington disputed the dependency and argued State Farm was the priority insurer.

The arbitrator analyzed the applicant's financial situation, including his receipt of welfare and student loans, and rejected the theoretical reports of both insurers' accounting experts.

The arbitrator concluded that the applicant was not principally financially dependent on his parents at the time of the accident.

Consequently, State Farm was found responsible for paying the applicant's benefits.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for her inability to perform essential housekeeping and childcare tasks.

The insurer terminated her weekly benefits, arguing symptom exaggeration based on some medical assessments.

The arbitrator reviewed conflicting medical and psychological evidence, including diagnoses of severe post-traumatic stress disorder from multiple specialists.

The arbitrator concluded that the applicant suffered a substantial inability to complete her essential tasks as a homemaker and mother due to the psychological effects of the accident, and awarded weekly benefits, interest, and expenses.

The applicant sought to arbitrate a claim for statutory accident benefits after her benefits were terminated.

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

The arbitrator found that the insurer failed to provide clear and unequivocal written notice of its refusal to pay benefits as required by s. 24(8) of the Statutory Accident Benefits Schedule.

Consequently, the limitation period was not triggered, and the applicant was permitted to proceed to arbitration on the merits.

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 but failed to attend the hearing or produce required medical and financial documentation.

The arbitrator dismissed the applicant's claim due to lack of evidence.

Finding the applicant's pursuit of the claim to be vexatious and an abuse of process, the arbitrator ordered the applicant to pay the insurer $1,000 for the arbitration assessment fee.

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

The applicant sought reinstatement of benefits, arguing he was either on a temporary lay-off or employed for 180 days in the twelve months preceding the accident.

The insurer argued the applicant did not qualify and sought repayment of benefits previously paid, alleging the applicant misrepresented his employment status.

The arbitrator found that the applicant retained his employment status while receiving workers' compensation benefits, thus satisfying the 180-day employment requirement.

The arbitrator also found the applicant did not knowingly misrepresent his status, dismissing the insurer's claim for repayment.

The applicant was awarded reinstatement of weekly income benefits and arbitration expenses.

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

The applicant sought arbitration for ongoing weekly income benefits, claiming an inability to perform his pre-accident duties as a health care aide due to back pain.

The arbitrator reviewed medical evidence and the physical demands of the occupation, concluding that the applicant did not suffer a substantial inability to perform the essential tasks of his employment.

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

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

The insurer subsequently terminated the benefits and sought repayment, alleging the applicant had misrepresented his pre-accident employment and income.

The arbitrator found the applicant's evidence regarding his employment to be contradictory and unsubstantiated, determining his weekly income benefits should be based solely on his verifiable employment.

The arbitrator also accepted expert evidence that the applicant was malingering and feigning psychological injuries, concluding he was not entitled to ongoing benefits.

The applicant was ordered to repay $16,233.06 in overpaid benefits and $1,000 in arbitration expenses for advancing a frivolous claim.

The Applicant was injured in a motor vehicle accident and received weekly income benefits of $185.60 based on her part-time employment.

She applied for arbitration, claiming her benefits should be $478.77 per week based on potential income from a street vending business she was attempting to start before the accident.

The arbitrator found that the statutory accident benefits scheme compensates for actual loss of income, not loss of potential or future business profits.

The Applicant's claim for higher benefits was dismissed, and her entitlement was confirmed at $185.60 per week.

The insurer, Canadian General Insurance Company, sought an extension of time to appeal an arbitrator's decision regarding priority for payment of statutory accident benefits, and alternatively applied to vary or revoke the order.

The insurer argued that a subsequent Ontario Insurance Commission bulletin and a court decision in a different case constituted grounds for relief.

The Director of Arbitrations dismissed the appeal, finding that a conflicting court decision does not constitute an apparent ground for granting an extension of time to appeal.

The variation application was also dismissed, as there was no material change in the insured's circumstances, no new evidence, and the alleged error of law was properly the subject of an appeal rather than a variation application.

The Applicant sought statutory accident benefits following a motor vehicle accident in a car wash.

She claimed income replacement benefits based on an alleged job offer, other disability benefits, and transportation expenses.

The arbitrator dismissed the claim for income replacement benefits, finding no contract of employment existed prior to the accident.

The claim for other disability benefits was also dismissed, as the Applicant failed to establish a substantial inability to engage in her pre-accident activities or that her complaints were caused by the accident rather than pre-existing conditions.

The Insurer had already paid reasonable transportation expenses.

The Applicant's request for arbitration expenses was denied due to her refusal to disclose essential medical evidence.

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

The Insurer terminated benefits after the Applicant returned to work full-time for over 90 days following the two-year anniversary of the accident, relying on section 16(2) of the Statutory Accident Benefits Schedule.

On a preliminary issue, the Arbitrator found that while the Applicant had worked for a continuous period of 90 days, section 16(2) does not automatically preclude a claim for further benefits.

Instead, it shifts the onus to the Applicant to re-establish the causal link between the accident and the disability.

The preliminary objection was dismissed.

The applicant sought to appeal an arbitrator's decision denying him weekly income benefits on the basis that he drove a company van without the owner's consent.

The applicant failed to file a proper Notice of Appeal within the 30-day statutory time limit and experienced significant delays, partly due to a refusal of legal aid.

The Director's Delegate refused to extend the time for the appeal, finding no reasonable grounds for the delay and no apparent grounds for granting the relief sought, as the arbitrator's findings on credibility, witness independence, and procedural fairness were sound.

The appeal was dismissed.

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

The insurer raised preliminary issues, arguing that the applicant had signed a full and final release settling all claims for $20,000.

The applicant contended he signed the release under duress.

The arbitrator found no evidence of duress and concluded the applicant understood the release, having previously signed a similar one.

The arbitrator held the applicant could not proceed to arbitration.

Due to the applicant's abusive and disruptive conduct, which unreasonably prolonged the proceedings, his claim for expenses was denied.

The arbitrator awarded $2,000 to the insurer, finding the arbitration was frivolous, vexatious, and an abuse of process.

The applicant, a registered nurse, was seriously injured in a motor vehicle accident and received weekly income benefits for three years.

The insurer terminated benefits, arguing she could return to part-time, less demanding employment.

The arbitrator found that the applicant's residual spinal cord injury, combined with the competitive job market, prevented her from returning to any suitable employment without retraining.

The arbitrator held that the applicant remained continuously prevented from engaging in suitable employment and was entitled to ongoing weekly income benefits.

The applicant was injured in a motor vehicle accident and received statutory accident benefits until the insurer terminated them in March 1992.

The insurer brought a preliminary issue motion arguing the applicant's March 1995 application for arbitration was barred by the two-year limitation period under s. 281(5) of the Insurance Act.

The arbitrator found the insurer had provided clear, unequivocal written notice of its refusal to pay further benefits by September 1992.

As the application was filed more than two years after this refusal, it was statute-barred.

The arbitrator declined to order the applicant to refund the insurer's $2,000 assessment fee, finding the applicant was confused by the process rather than acting frivolously.

The applicant was injured in a motor vehicle accident and required long-term care in a facility.

The insurer paid the facility's cost but deducted the amount the applicant paid for rent prior to the accident, arguing that paying the full amount would result in a windfall.

The arbitrator held that the accommodation expenses fell under section 7 of the Statutory Accident Benefits Schedule as care benefits.

The arbitrator found that the insurer was not entitled to deduct pre-accident housing costs, as the applicant's life had completely changed and the full cost of the facility was a reasonable expense resulting from the accident.

The applicant's claim for a special award was dismissed.