OFSCDRS 1996

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

The insurer terminated benefits, arguing the applicant was capable of working and that his disability was caused by his bankruptcy rather than the accident.

The arbitrator found that the applicant suffered from chronic pain syndrome caused by the accident, which continuously prevented him from engaging in any occupation for which he was reasonably suited by education, training, or experience.

The arbitrator also found that the parties had previously settled the quantum of benefits at $600 per week.

The insurer's claim for repayment was dismissed.

A special award of $600 was granted because the insurer unreasonably withheld benefits by failing to provide proper notice of its reasons for termination.

The Applicant was injured in a motor vehicle accident and sought ongoing weekly income benefits under section 13 of the Statutory Accident Benefits Schedule after the Insurer terminated them.

The arbitrator found that the Applicant was capable of returning to her pre-accident activities by October 7, 1994, and was therefore entitled to benefits up to that date.

However, because the Applicant received Canada Pension Plan and Workers' Compensation benefits that exceeded her accident benefits entitlement, she was not owed any further payments.

Furthermore, the arbitrator ordered the Applicant to repay $1,100.00 in overpaid benefits to the Insurer and denied her costs of the arbitration due to her exaggeration of her pre- and post-accident condition.

The applicant was injured in a motor vehicle accident and claimed statutory accident benefits, asserting he was a successful self-employed jewellery manufacturer.

The insurer paid the maximum weekly income benefit of $600 based on a purported purchase order.

The arbitrator found that the applicant had fraudulently misrepresented the status of his business and the existence of the purchase order, and that the insurer had erred in calculating benefits based on anticipated rather than earned income.

The applicant was found to be self-employed but only entitled to the minimum weekly benefit of $185.60 for 156 weeks.

The insurer was awarded a repayment of $21,446.40 for the overpayment.

Claims for benefits beyond 156 weeks and a special award were dismissed.

The applicant was injured in a snowmobile accident and received caregiver benefits until the insurer terminated them.

The arbitrator found that the applicant was deemed to have elected caregiver benefits.

While the applicant did not suffer a substantial inability to engage in caregiving activities after the termination date, she did suffer a partial inability to carry on a normal life due to her restricted mobility.

The arbitrator awarded caregiver benefits for the 104-week period following the accident, along with interest and expenses.

The applicant was injured when she slipped and fell on a transit bus.

She received statutory accident benefits, but the insurer terminated her weekly income benefits after she returned to work.

The applicant later stopped working due to another workplace incident and sought reinstatement of her weekly income benefits, as well as medication and travel expenses.

The arbitrator found insufficient medical evidence connecting her ongoing inability to work to the bus accident, relying on medical reports indicating her injuries should not prevent her from performing her normal activities.

The claims for weekly income benefits and medical expenses were dismissed, though the applicant was awarded her hearing expenses.

The applicant, a minor, claimed a death benefit following the death of her mother in a motor vehicle accident.

The insurer denied the claim on the basis that the applicant was living with her grandparents at the time of the accident and was therefore not principally dependent on her mother.

The arbitrator found that the living arrangement with the grandparents was temporary due to an abusive stepfather, and that the applicant remained principally dependent on her mother for financial support and care.

The applicant was awarded the death benefit of $10,020.00 plus interest and expenses.

The appellant, a homemaker injured in a motor vehicle accident, appealed an arbitrator's decision denying her ongoing weekly benefits under section 13 of the Statutory Accident Benefits Schedule.

The appellant argued the arbitrator applied an overly strict test, improperly relied on surveillance evidence showing her visiting a grave, and erred in considering her lack of cooperation with rehabilitation.

The Director's Delegate dismissed the appeal, finding the arbitrator correctly assessed whether the appellant was substantially unable to perform her essential tasks, and reasonably considered her ability to modify tasks, the surveillance evidence, and her failure to pursue rehabilitation.

The appellant was awarded her appeal expenses.

The insurer appealed an arbitration order granting the insured weekly benefits and housekeeping expenses following a motor vehicle accident.

The insurer argued the arbitrator misconstrued medical evidence regarding the insured's ability to perform essential tasks and erred in awarding housekeeping expenses for services provided by family members.

The Director of Arbitrations dismissed the appeal, finding the arbitrator's conclusions on disability were supported by the evidence.

The Director also upheld the housekeeping award, confirming that paragraph 6(1)(f) of the Schedule allows compensation for reasonable services provided by family members when required for the insured's care or rehabilitation.

The applicant was injured in a motor vehicle accident and sought a determination of the quantum of his weekly income benefits.

The arbitrator had to decide whether to calculate the applicant's pre-accident income by averaging his earnings over the 22 weeks he actually worked, or over the full 52 weeks preceding the accident.

Following previous tribunal decisions, the arbitrator held that the plain language of the Statutory Accident Benefits Schedule required averaging the income over 52 weeks, resulting in a weekly benefit of $250.22.

The arbitrator denied the applicant's request for a special award for unreasonably withheld benefits, noting that the delay was partly attributable to the applicant's refusal to include the quantum issue in the initial hearing.

The insurer's request for costs was denied, and the applicant was awarded his expenses for the arbitration.

The appellant sought to appeal an arbitration order that dismissed his claim for statutory accident benefits after he failed to attend the arbitration hearing.

The notice of appeal was filed almost five months after the order, well beyond the 30-day limit.

The appellant requested an extension of time under section 283(3) of the Insurance Act, claiming he missed the hearing because he was misinformed about an adjournment and subsequently suffered a breakdown.

The Director's Delegate rejected the appellant's explanation as not credible and found no apparent grounds for granting relief on the merits of the claim.

The motion to extend the time was denied and the appeal was dismissed.

State Farm appealed an arbitration decision finding it liable to pay statutory accident benefits to a claimant who was listed as a driver on her parents' policy but injured while an occupant in a vehicle insured by Pilot.

Pilot cross-appealed the finding that the claimant was not a dependant of her parents.

The Director's Delegate allowed State Farm's appeal, holding that being a listed driver does not make one an 'insured person' under the Statutory Accident Benefits Schedule for accidents in other vehicles.

The Delegate dismissed Pilot's cross-appeal, upholding the arbitrator's finding that the 18-year-old claimant was living independently and was not principally dependent on her parents for financial support.

Pilot was ordered to pay the accident benefits.

The applicant was injured in a motor vehicle accident and received statutory accident benefits until May 1992.

He sought further weekly benefits, rehabilitation expenses, and a special award.

The arbitrator found the applicant lacked credibility and that he was substantially able to perform his essential tasks after May 1992, dismissing the claim for ongoing weekly benefits.

Furthermore, the arbitrator found the applicant had attended school full-time between January and May 1992, precluding him from receiving benefits during that period, and ordered him to repay the benefits received.

The insurer was ordered to pay an outstanding rehabilitation account that had been pre-approved.

The insurer was also awarded $500 because the applicant's conduct unreasonably prolonged the proceedings and parts of the claim were without merit.

The Applicant was injured in a motor vehicle accident and applied for statutory accident benefits more than two years after the accident.

The Insurer refused benefits due to non-compliance with the time limits in section 22 of the Statutory Accident Benefits Schedule.

The Applicant sought relief from forfeiture under section 129 of the Insurance Act.

The Arbitrator held that section 22(2) provides the only relief from forfeiture for the time limits in section 22(1), and that an arbitrator is not a 'court' with jurisdiction to grant equitable relief under section 129.

The Applicant was therefore precluded from proceeding to arbitration.

The appellant insurer appealed an arbitration order requiring it to pay the respondent additional weekly income benefits.

The respondent, a self-employed plumber, was injured in a motor vehicle accident but provided unreliable evidence regarding his pre- and post-accident income.

The Director's Delegate upheld the finding that the respondent was entitled to some benefits but found the arbitrator erred in calculating the quantum and the termination date.

The Delegate recalculated the benefits, finding the respondent had been overpaid by $8,987.92, and ordered him to repay this amount with interest.

The Delegate also overturned the award of interest on overdue payments, finding the payments were not overdue until finally determined because the respondent's misrepresentations made it impossible for the insurer to determine the correct amount.

The appellant was injured in a snowmobile accident and received statutory accident benefits until they were terminated by the insurer.

An arbitrator dismissed his claims for ongoing weekly benefits, primary caregiver benefits, and expenses for various goods and services, but awarded him arbitration expenses.

The appellant appealed the arbitrator's findings on his inability to perform essential tasks, and the insurer cross-appealed the award of expenses.

The Director of Arbitrations dismissed both the appeal and cross-appeal, finding that the arbitrator applied the correct legal tests, made factual findings supported by the evidence, and appropriately exercised discretion in awarding expenses.

The insurer appealed an arbitration order awarding the claimant $3,720 for babysitting and housekeeping services under paragraph 6(1)(f) of the Statutory Accident Benefits Schedule.

The insurer argued that because the claimant was already receiving weekly benefits as an unemployed primary caregiver under section 13, he was precluded from recovering replacement services under section 6.

The Director of Arbitrations dismissed the appeal, holding that receipt of section 13 benefits does not foreclose recovery of supplementary care benefits under section 6, provided the expenses relate to the insured person's own needs.

The Director also declined to interfere with the arbitrator's factual findings regarding the apportionment of the housekeeper's duties.

The respondent was injured in a motor vehicle accident while vacationing in Vietnam.

She applied for statutory accident benefits under a standard motor vehicle liability policy issued by the appellant.

The appellant denied the claim on the basis that the policy applies only to accidents in Canada, the United States, or on a vessel travelling between the ports of those countries.

An arbitrator initially held that the Statutory Accident Benefits Schedule operated without territorial limitation.

On appeal, the Director of Arbitrations allowed the appeal, finding that the Schedule does not operate independently of the contract of insurance, which contains a valid territorial limitation.

The respondent was therefore not eligible to receive benefits for the accident in Vietnam.

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

The applicant applied for arbitration to claim ongoing weekly income benefits.

The arbitrator found the applicant's evidence regarding his pre-accident medical condition and employment status lacked credibility, noting significant pre-existing back and neck issues.

The arbitrator concluded the applicant failed to establish the essential tasks of his pre-accident employment and failed to prove his current medical difficulties were causally related to the motor vehicle accidents.

The claim for ongoing benefits was dismissed, but the applicant was awarded one-half of his arbitration expenses.

The appellant was injured in a motor vehicle accident but did not submit an application for statutory accident benefits until more than two years later.

The insurer denied the claim as out-of-time.

The appellant argued the insurer waived or was estopped from relying on the time limits because it failed to provide an application form, investigated the late claim, and obtained medical information without a non-waiver agreement.

The Director's Delegate upheld the arbitrator's decision, finding no intentional relinquishment of rights by the insurer and no detrimental reliance by the appellant.

The appeal was dismissed and expenses were denied.

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

The applicant applied for arbitration, claiming ongoing weekly income benefits on the basis that severe, unpredictable headaches caused by the accident continuously prevented him from engaging in any occupation for which he was reasonably suited.

The Arbitrator found the applicant credible and accepted medical evidence that his severe headaches were debilitating and unpredictable.

The Arbitrator concluded that the applicant was continuously prevented from engaging in suitable employment and ordered the insurer to pay ongoing weekly income benefits and arbitration expenses.