OFSCDRS 1996

The applicant was injured in a motor vehicle accident and claimed ongoing weekly income benefits and supplementary medical and rehabilitation benefits.

The insurer terminated benefits and sought repayment, arguing the applicant was not disabled and had returned to work at his pizza store.

The arbitrator found the applicant to be an unreliable and evasive witness, relying on surveillance video showing him working.

The medical evidence supporting disability was rejected due to partiality and lack of complete history.

The applicant's claims for ongoing benefits were dismissed, as was the insurer's claim for repayment.

No expenses were awarded to the applicant due to his lack of credibility.

The applicant was injured in a motor vehicle accident in February 1993, his fourth accident in two years.

He applied for statutory accident benefits, and the insurer terminated his weekly income benefits in July 1993.

The arbitrator found that the accident materially contributed to the applicant's disability but concluded that the effects of the accident had resolved by October 13, 1993.

The arbitrator determined the correct quantum of weekly benefits by averaging the applicant's pre-accident income over 52 weeks, rather than just the weeks worked.

The applicant was ordered to repay collateral benefits received from a disability policy, but was not required to repay the insurer's overpayment of weekly benefits because the error was the insurer's.

The applicant was awarded his expenses of the arbitration.

The applicant, an 87-year-old woman, was injured in a motor vehicle accident and sought ongoing weekly and care benefits after the insurer terminated them.

The insurer raised a preliminary issue that the applicant failed to attend an independent medical examination.

The arbitrator found the applicant had a reasonable excuse for missing the examination and was not precluded from proceeding.

On the merits, the arbitrator found the applicant suffered a substantial inability to perform her essential tasks due to physical and psychological injuries from the accident, entitling her to ongoing weekly benefits.

The arbitrator also awarded ongoing care benefits at $250 per week and a $2,000 special award under section 282(10) of the Insurance Act, finding the insurer unreasonably terminated benefits without a sound basis.

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

After disputes arose, she applied for arbitration but withdrew her application shortly before the hearing after her request for an adjournment was denied.

She later sought to refile her application.

The arbitrator found that her withdrawal was an abuse of process, as she had no reasonable grounds for an adjournment and withdrew to subvert the Commission's process.

However, balancing her right to a hearing, the arbitrator permitted her to refile on the condition that she pay the maximum statutory assessment fee of $1,000 to the insurer before proceeding.

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

A dispute arose regarding the calculation of his pre-accident gross weekly income as a self-employed ceramic tile setter, as he had poor business records.

The arbitrator accepted reconstructed invoices as reliable evidence of his actual earnings.

The arbitrator calculated the applicant's gross weekly income and awarded a weekly income benefit of $550.52.

The arbitrator also held that the application for benefits was 'completed' when it was filled in, signed, and provided to the insurer, entitling the applicant to interest on overdue payments from 30 days after that date.

The Applicant's husband was killed in a motor vehicle accident.

The Applicant received a spousal death benefit but applied for an additional dependant's benefit under section 11(2)(c) of the Statutory Accident Benefits Schedule, arguing she was principally dependent on her husband because she planned to take maternity leave.

The arbitrator found that dependency must be assessed exactly at the time of the accident.

At that time, the Applicant was working full-time and earning more than her husband.

Therefore, she was not principally dependent on him for financial support and was not entitled to the dependant's benefit.

The Applicant was awarded her arbitration expenses.

The appellant appealed an arbitration order that denied him statutory accident benefits after his request for an adjournment was refused.

The appellant had retained new counsel shortly before the hearing, but his former counsel refused to release the file without an unconditional guarantee of his account.

The arbitrator, unaware of these specific efforts and the former counsel's refusal, denied the adjournment and dismissed the claim when no evidence was presented.

On appeal, the Director's Delegate found that the arbitrator had exercised his discretion based on misapprehended facts.

The appeal was allowed, the arbitration order was rescinded, and the matter was remitted for a new hearing.

The appellant appealed an arbitration decision that dismissed his claim for weekly income benefits after he and his representative failed to present evidence at the hearing.

The appellant requested an extension of the 30-day appeal period, which was granted.

On the merits of the appeal, the appellant argued the arbitrator erred in refusing an adjournment to allow him to retain new counsel.

The Director's Delegate dismissed the appeal, finding that the arbitrator correctly refused the adjournment because the appellant provided no valid reason for being unprepared and had acted irresponsibly.

The appellant was denied his appeal expenses.

The Arbitrator issued a correction to a previous decision dated January 24, 1996, to amend the name of the insurer's representative from Harry P. Brown to Mark W. Sones.

The applicant sought an extension of time to appeal an arbitration decision that dismissed his claim for weekly income benefits.

The applicant's agent had failed to present evidence at the original hearing after an adjournment request was denied.

The applicant subsequently retained a lawyer who filed the notice of appeal 80 days after the decision was issued, well beyond the 30-day statutory limit.

The Director's Delegate considered whether there were reasonable grounds for the delay and apparent grounds for granting the extension.

The applicant was injured in a motorcycle accident, sustaining severe lacerations to his left hand that severed tendons and nerves.

The insurer terminated his weekly income benefits after 156 weeks, arguing he was reasonably suited for alternative occupations.

The arbitrator found that the applicant's education, training, and experience did not equip him for the sedentary or service occupations proposed by the insurer's vocational expert.

The arbitrator concluded the applicant remained continuously prevented from engaging in suitable employment and ordered the insurer to pay ongoing weekly income benefits, interest, and arbitration expenses.

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

She applied for arbitration, claiming a substantial inability to perform the essential tasks of her pre-accident employment as a cook.

The arbitrator reviewed medical evidence, including functional capacity assessments and expert reports, which indicated she was capable of returning to work with minor restrictions.

Finding the applicant's testimony regarding her limitations lacked credibility and was inconsistent with her activities, the arbitrator concluded she did not suffer a substantial inability to perform her essential tasks and dismissed the claim for further benefits, though awarded her arbitration expenses.

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

The applicant sought arbitration for continued benefits, claiming she remained substantially unable to perform the essential tasks of her employment as a store manager.

The arbitrator found the applicant's evidence unreliable and preferred the results of a functional capacity evaluation which indicated she was capable of returning to work.

The arbitrator concluded the applicant was not substantially disabled and dismissed the claim for further income benefits, but awarded the applicant her expenses for the arbitration.

The applicant was injured when he slipped on ice while exiting his van.

The insurer denied his claim for statutory accident benefits on the basis that the injury was not caused by an 'accident' as defined in section 2 of the Statutory Accident Benefits Schedule.

The arbitrator applied the broad interpretation from the Supreme Court of Canada's decision in Amos, finding that exiting a vehicle is an ordinary and well-known activity to which automobiles are put, and that the use of the van contributed to the injury.

The arbitrator concluded that the applicant was injured in an accident and is eligible for benefits.

The insurer appealed a preliminary arbitration decision finding that the insured was not disentitled to weekly income benefits under section 16(2) of the Schedule, as she had not worked for a continuous period of 90 days after the two-year anniversary of the accident.

The insured appealed a subsequent arbitration decision finding she was no longer eligible for weekly income benefits under section 12(1).

The Director's Delegate dismissed both appeals, upholding the arbitrator's interpretation of section 16(2) as referring to continuous periods of work, and finding no error in the arbitrator's evaluation of the evidence regarding the insured's eligibility.

The insurer was ordered to pay the insured's expenses for the preliminary issue appeal, but no expenses were awarded for the eligibility appeal.

The applicant, on behalf of her minor daughter who suffered a spinal cord injury in a motor vehicle accident, sought statutory accident benefits for the purchase of a new home.

The insurer argued its obligation was limited under subsection 41(1) of the 1994 Schedule to the cost of renovating the daughter's 'existing home', which was a townhouse owned by her mother's estranged husband.

The arbitrator held that the townhouse was the 'existing home' despite the lack of ownership by the insured, and that the insurer's present obligation towards a new home was restricted to the value of the renovations that would have been required for the townhouse.

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

The insurer terminated benefits, arguing the applicant no longer met the stricter disability test under section 12(5)(b) of the Statutory Accident Benefits Schedule.

The arbitrator found that while the applicant suffered from chronic back pain and might be disabled from his pre-accident heavy manual job, he failed to prove that his injuries continuously prevented him from engaging in any occupation or employment for which he was reasonably suited by education, training, or experience.

The application for further weekly income benefits was dismissed, but the insurer was ordered to pay the applicant's arbitration expenses.

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

The insurer paid some initial chiropractic and travel expenses but denied further claims.

The applicant sought arbitration for supplementary medical rehabilitation expenses, weekly income benefits, and a special award.

The arbitrator allowed the claim for specific chiropractic treatments and associated travel expenses incurred in 1992, finding them reasonable and necessary.

However, claims for housekeeping expenses, herbal remedies, a spa, and weekly income benefits were dismissed due to a lack of medical evidence connecting them to the accident.

The request for a special award was also denied, as the insurer had not acted unreasonably.

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 regarding entitlement to weekly income benefits.

At a pre-hearing, the Insurer sought to add the issues of quantum and repayment of benefits to the arbitration, which the Applicant opposed.

The Arbitrator held that an arbitrator has jurisdiction under the Insurance Act and the Statutory Powers Procedure Act to add issues not raised by the applicant, provided they have been mediated, are reasonably incidental to the applicant's issues, and do not unduly expand the scope of the inquiry.

The Arbitrator found that quantum and repayment were reasonably incidental to the issue of entitlement and added them to the arbitration.

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

The Insurer terminated weekly income benefits, but after mediation, the parties settled for a specific period and the Applicant signed a release.

The Insurer argued the release barred future claims and that the two-year limitation period had expired.

The Arbitrator found the release was confined to the specific period settled at mediation and did not bar future claims.

Furthermore, the limitation period had not begun to run because the Insurer failed to provide clear and unequivocal written notice of its refusal to pay benefits after the settlement, as required by the Schedule.

The Applicant was permitted to proceed to arbitration.