OFSCDRS 1996

The applicant claimed statutory accident benefits following a motor vehicle accident but failed to take any steps to advance the arbitration after a preliminary issue was decided in December 1995.

The insurer brought a motion to dismiss the arbitration.

The applicant did not attend the hearing despite receiving proper notice.

The arbitrator proceeded in the applicant's absence under the Statutory Powers Procedure Act and dismissed the claims on the merits, finding the applicant had abandoned the arbitration and failed to satisfy his burden of proof.

The insurer appealed an arbitration decision that found the insured met the post-156 week test for weekly income benefits.

The insurer argued the insured's post-accident employment income was roughly equivalent to his pre-accident income, demonstrating he was able to maintain employment for which he was reasonably suited.

Following a partial rehearing where additional financial records were produced, the insurer conceded the insured's pre-accident income was substantially higher.

The Director's Delegate dismissed the appeal, confirming the insured's entitlement to weekly income benefits at the maximum rate of $600 per week, subject to deductions for post-accident income, and awarded limited interest and appeal expenses.

The appellant was injured in a motor vehicle accident and received weekly income benefits of $600 based on reported pre-accident income.

The insurer later reduced benefits, alleging the income information was false and seeking repayment of an overpayment.

At arbitration, the arbitrator found the appellant and his witnesses lied about his employment and ordered repayment.

On appeal, the Director's Delegate found the arbitrator failed to adequately explain the finding of fraud, particularly given the existence of tax documents supporting the income.

The appeal was allowed in part, and a new hearing was ordered to determine the proper amount of benefits and any overpayment.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits from the insurer.

The insurer denied coverage, claiming the applicant had requested to delete all road coverages the day before the accident.

The applicant argued the broker made an error regarding the effective date of the coverage change.

The arbitrator found that the applicant was an insured person at the time of the accident because the broker's error could not unilaterally alter the contract.

However, the arbitrator also held that the applicant was barred from proceeding with his claim because he failed to submit a completed application for statutory accident benefits within the required time limits under section 22(1)(b) of the Statutory Accident Benefits Schedule, and the insurer's denial of coverage did not estop them from relying on this requirement.

The appellant, a self-employed individual injured in a motor vehicle accident, appealed an arbitration decision regarding the calculation of his weekly income benefits.

The core issue was the arbitrator's interpretation of 'ceasing expenses' under the Statutory Accident Benefits Schedule, specifically whether a proportional reduction in ongoing business expenses qualified as a ceasing expense.

The Director of Arbitrations dismissed the appeal, finding that the arbitrator's factual findings and legal conclusions were supported by the evidence.

The Director also refused to admit new evidence regarding the post-hearing purchase of a cellular telephone, as it did not meet the criteria for admission on appeal and could not affect the original calculation.

The applicants were injured in a motor vehicle accident and sought statutory accident benefits.

The insurer terminated the husband's weekly income benefits, prompting an arbitration.

The arbitrator found that the husband was entitled to benefits for a limited period but had failed to disclose post-accident self-employment income, resulting in a substantial overpayment.

Surveillance evidence demonstrated the husband was capable of performing his pre-accident work.

The husband was ordered to repay over $92,000 to the insurer.

The wife was found to have been underpaid and was awarded the balance owed.

The insurer applied to vary an arbitration order, arguing the arbitrator erred by refusing to deal with the deductibility of the insured's Canada Pension Plan (CPP) disability benefits and the insurer's claim for repayment of benefits.

The Director of Arbitrations found that the arbitrator erred in concluding that no repayment was sought by the insurer, as the record showed the insurer had raised the issue of deductibility for both past and future benefits.

The application to vary was granted, and the issues of CPP deductibility and repayment were remitted for adjudication.

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

He applied for statutory accident benefits from Allstate, which refused payment on the basis that he was a dependant of his mother and should claim from her insurer, General Accident.

The arbitrator held a preliminary issue hearing to determine priority.

Finding that the applicant operated a cash business and was not principally dependent for financial support on his mother, the arbitrator concluded he was not a dependant.

Allstate was ordered to pay the benefits.

The applicant was denied his expenses due to his misrepresentations regarding his employment and income.

The Applicant was injured in a rear-end motor vehicle accident and received weekly income replacement benefits.

The Insurer terminated these benefits based on a report from a chiropractor acting as a designated assessment centre, who admitted the Applicant's temporomandibular joint injury was beyond his expertise but nonetheless concluded she was not physically disabled.

The Applicant sought arbitration for ongoing benefits and a special award.

The Arbitrator found that the Applicant remained disabled until December 4, 1995, after which her ongoing issues were caused by her failure to follow medical advice to stop working late nights as a karaoke hostess.

The Arbitrator awarded income replacement benefits for the period of disability and granted a $2,000 special award under section 282(10) of the Insurance Act, finding the Insurer acted unreasonably in terminating benefits based on an assessor who lacked the expertise to evaluate the specific impairment.

The appellant sought to appeal an arbitration decision that denied his claim for ongoing weekly income benefits for a psychological injury allegedly caused by a motor vehicle accident.

The appellant requested a referral to the Medical and Rehabilitation Advisory Panel, the admission of fresh evidence regarding an expert witness's credibility, or a new hearing.

The Director of Arbitrations dismissed the appeal, finding no basis to refer the matter to the panel, refusing to admit the new evidence as it could have been produced earlier or was irrelevant to the expert's medical opinion, and concluding there were no grounds to order a new hearing.

The appellant was injured while travelling as a passenger on a bus and received statutory accident benefits until they were terminated by the insurer.

At arbitration, it was determined that the appellant did not suffer a substantial inability to perform his essential tasks after the termination date.

The appellant appealed, arguing the arbitrator failed to accord appropriate weight to medical reports and misapplied the law.

The Director of Arbitrations dismissed the appeal, finding that the arbitrator's factual conclusions were supported by the evidence and that she correctly applied the provisions of the Statutory Accident Benefits Schedule to those findings.

The applicant sought statutory accident benefits after allegedly slipping and falling while exiting a bus.

The insurer denied the claim, arguing the incident was not an 'accident' under the Schedule and that the applicant failed to submit her application within 90 days.

The arbitrator found that the applicant fell while alighting from the bus, meaning the use or operation of an automobile caused the incident.

Furthermore, although the applicant failed to submit the application within 90 days, the insurer was estopped from relying on this defence due to the adjuster's representations that the claim was being processed.

The applicant applied for arbitration after the insurer terminated his weekly income benefits following a motor vehicle accident.

The applicant failed to attend the pre-hearing and the hearing, despite receiving proper notice.

The arbitrator dismissed the applicant's claim due to his failure to pursue it and present evidence.

The arbitrator found the applicant's conduct to be vexatious and an abuse of process, ordering him to pay the insurer's $2,000 assessment fee.

The insurer's request for repayment of benefits was dismissed, as a counterclaim cannot stand alone once the main application is dismissed.

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

She applied for arbitration, claiming she developed a chronic pain condition rendering her continuously disabled from returning to work.

The arbitrator found the applicant's credibility to be seriously questionable due to inconsistencies and denials of her physical abilities.

Relying on medical evidence that identified pre-existing degenerative disease, emotional depression, and other psycho-social factors as the primary causes of her ongoing disability, the arbitrator concluded the accident was not a significant contributing factor.

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

The appellant, a pedestrian injured in a motor vehicle accident, appealed an arbitration decision that terminated his weekly income benefits and ordered him to repay overpaid benefits.

The Director of Arbitrations upheld the arbitrator's findings that the appellant was no longer substantially unable to perform the essential tasks of his occupation, based on medical and rehabilitation evidence.

Furthermore, the Director affirmed the arbitrator's conclusion that the appellant's financial records were unreliable and constructed after the accident, justifying the calculation of his income benefits at the minimum rate.

The appeal was dismissed.

The applicant was struck by a bus while walking to work and sustained a head injury resulting in chronic headaches, depression, anxiety, and cognitive difficulties.

The insurer terminated her weekly income benefits after 104 weeks, arguing she was not disabled from returning to reasonably suitable employment or that her disability was due to pre-existing conditions.

The arbitrator found the applicant credible and preferred the evidence of her treating medical practitioners over the insurer's assessors who only saw her once or twice.

The arbitrator concluded that the applicant's complex of psychological, emotional, and cognitive symptoms substantially disabled her from engaging in any employment for which she was reasonably suited.

The insurer was ordered to reinstate weekly income benefits with interest and pay the applicant's arbitration expenses.

The appellant, a martial arts instructor injured in a motor vehicle accident, appealed an arbitration decision that terminated his weekly income benefits and ordered repayment of amounts paid above the statutory minimum.

The Director of Arbitrations dismissed the appeal, finding the arbitrator did not misinterpret the test for 'substantial inability to perform essential tasks' and reasonably relied on surveillance and medical evidence.

Furthermore, the arbitrator correctly awarded only the minimum benefit because the appellant's financial evidence regarding his pre- and post-accident income was unreliable and contradictory.

The appellant was injured in a motor vehicle accident and sought weekly income benefits.

At arbitration, he was awarded the minimum weekly amount because he failed to prove a higher pre-accident income, having relied on unreported cash taken from his business.

On appeal, the appellant sought to introduce fresh evidence of his living expenses to prove he must have earned a higher income, and requested a rehearing.

The Director of Arbitrations dismissed the appeal, finding that the fresh evidence was available at the time of the hearing and would not prove the source of the income.

The request for a rehearing was also denied, as the arbitrator's findings of fact were supported by the evidence.

The applicant, a self-employed excavating contractor, was injured in a motor vehicle accident and claimed statutory accident benefits.

The parties disputed the calculation of his weekly income benefits, specifically regarding which business expenses continued after the accident.

The arbitrator determined the applicant's pre-accident net income and added verifiable continuing expenses (depreciation, telephone, and motor vehicle fuel) to calculate the gross weekly income, resulting in a total entitlement of $54,535.32 up to the hearing date.

Because the insurer had already paid over $61,000, there was an overpayment.

The arbitrator ordered the applicant to repay $450, finding no fraud or error for the remainder of the overpayment.

The applicant's claims for a special award were dismissed, but he was awarded his arbitration expenses.

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

He claimed statutory accident benefits under an automobile insurance policy.

The arbitrator found that the starting of the car engine constituted the use or operation of an automobile and was the precipitating cause of the injury.

The insurer appealed.

The Director's Delegate dismissed the appeal, holding that the phrase 'causes, directly or indirectly' in the Schedule allows for a more remote causal link than proximate cause, and that the starting of the engine triggered the sequence of events leading to the fall.