Cases from the Ontario Financial Services Commission - Dispute Resolution Services
Applicant ordered to repay accident benefits due to material misrepresentation and pay costs for vexatious conduct.
The applicant claimed statutory accident benefits following an alleged motor vehicle accident.
The insurer terminated weekly income benefits and sought repayment, alleging material misrepresentation regarding vehicle ownership and the applicant's driving record.
The arbitrator found the applicant's evidence regarding his disability and income to be wholly unreliable and contradictory.
The arbitrator concluded that the insurance contract was obtained through material misrepresentation, precluding the applicant from receiving weekly income benefits.
The applicant was ordered to repay all weekly income benefits received and to pay the insurer's assessment costs due to his frivolous, vexatious, and abusive conduct throughout the proceedings.
Applicant entitled to ongoing section 13 weekly benefits due to substantial inability to perform essential tasks.
The applicant was injured in a motor vehicle accident while participating in a workers' compensation retraining program.
He claimed ongoing weekly income benefits under section 12 or 13 of the Statutory Accident Benefits Schedule.
The arbitrator found that the applicant was not employed by the Workers' Compensation Board and did not qualify under section 12.
However, the arbitrator concluded that the applicant suffered a substantial inability to perform his essential tasks as a student due to chronic pain and reflex sympathetic dystrophy, entitling him to ongoing benefits under section 13.
The claim for a special award was dismissed for lack of jurisdiction as it had not been mediated.
Arbitrator corrected previous decision to award interest at 2% per month instead of per annum.
The Arbitrator issued a correction to a previous decision dated June 24, 1996.
The correction amended the interest rate awarded to the applicant from 2% per annum to 2% per month on any outstanding amounts.
Personal vehicle insurer, not taxi insurer, held responsible for statutory accident benefits of injured taxi driver.
The Applicant was injured in a motor vehicle accident while driving a taxi in the course of his employment.
He applied for statutory accident benefits from Allstate, which insured his personal vehicle.
Allstate argued that Wellington, which insured the taxi, was responsible.
The arbitrator determined that the Applicant was an 'insured person' under the Allstate policy and not a 'named insured' under the Wellington policy.
Therefore, Allstate was held responsible for paying the Applicant's statutory accident benefits.
Insured denied ongoing weekly income benefits; insurer denied repayment of $14,664 overpayment caused by its own adjusting errors.
The applicant was involved in two motor vehicle accidents and received weekly income benefits from the insurer.
The insurer terminated benefits, alleging the applicant was no longer disabled and had post-accident earnings resulting in an overpayment.
The arbitrator found the applicant failed to establish a substantial inability to perform her essential tasks after the termination date, relying on surveillance evidence and the unreliability of her testimony.
The arbitrator recalculated the benefit amounts and determined the insurer had overpaid the applicant by $14,664 due to a failure to deduct post-accident income.
However, the arbitrator declined to order repayment, finding the overpayment resulted primarily from the insurer's own adjusting errors rather than the applicant's misrepresentations.
Suicide by motor vehicle exhaust is not an 'accident' for the purpose of statutory accident benefits.
The insured person committed suicide by carbon monoxide poisoning in his parked car.
His widow applied for death and funeral benefits under his automobile insurance policy.
The insurer denied the claim on the basis that suicide is not an 'accident' under the Statutory Accident Benefits Schedule.
The arbitrator found in favour of the widow, concluding that the definition of 'accident' in the Schedule was broad enough to include suicide.
On appeal, the Director's Delegate reversed the arbitrator's decision, holding that the definition of 'accident' restricts rather than expands the common law meaning, and does not include intentional acts such as suicide.
The appeal was allowed and the claim for benefits was dismissed.
Insured awarded ongoing weekly income benefits and a $5,000 special award for insurer's unreasonable termination.
The applicant was injured in a motor vehicle accident and received statutory accident benefits until the insurer terminated them.
She applied for ongoing weekly income benefits, arguing she suffered from post-concussion syndrome and a brain injury that prevented her from working.
The insurer argued her inability to work was due to pre-existing psychological conditions and post-accident life events.
The arbitrator found that the accident materially contributed to her disability, exacerbating a pre-existing personality disorder, and that she was continuously prevented from engaging in suitable employment.
The arbitrator also ordered a $5,000 special award against the insurer for unreasonably terminating and withholding benefits based on a cursory neurological report while ignoring numerous other medical recommendations.
Common-law spousal status under the standard automobile policy ends when the parties cease cohabiting.
The appellant insurer appealed an arbitration decision finding it responsible for paying the respondent pedestrian's accident benefits.
The pedestrian was struck by a vehicle insured by the appellant.
She applied for benefits under a policy held by her former common-law partner, insured by the respondent insurer.
The arbitrator found that the pedestrian and the named insured were not spouses at the time of the accident because they had ceased cohabiting for over a year.
On appeal, the Director's Delegate upheld the decision, finding that a temporal connection is implicit in the definition of "spouse" under the Insurance Act and the standard automobile policy, and that non-married spousal status ends when the parties cease to cohabit in a relationship of some permanence.
Claim for weekly income benefits denied; chauffeur expenses for out-of-town medical appointments allowed.
The applicant was injured in a motor vehicle accident and sought statutory accident benefits, including weekly income benefits, transportation expenses, and chauffeur/companion expenses for her husband.
The arbitrator found that the applicant, who worked in her husband's family business, did not suffer a substantial inability to perform the essential tasks of her employment and denied the weekly income benefits.
The claim for an increased transportation allowance was dismissed for lack of proof.
However, the arbitrator allowed the claim for chauffeur/companion expenses for out-of-town medical appointments, awarding 108 hours at the minimum wage rate.
Weekly income benefits set at minimum rate after applicant failed to prove alleged cash earnings.
The Applicant was injured in a motor vehicle accident and received statutory accident benefits.
The Insurer reduced and later terminated his weekly income benefits, alleging an overpayment.
The Applicant sought arbitration, claiming his benefits should be based on a $2,400 cash contract he allegedly performed in the four weeks prior to the accident.
The arbitrator found the Applicant lacked credibility and failed to provide objective evidence of the alleged contract or earnings.
The arbitrator concluded the Applicant fabricated the contract to inflate his benefits, set the weekly income benefit at the minimum rate of $185.60, and denied the Applicant his expenses.
Applicant entitled to ongoing weekly income benefits as chronic pain syndrome prevented suitable alternative employment.
The applicant was injured in a motor vehicle accident and received weekly income benefits until the insurer terminated them.
The applicant applied for arbitration, claiming ongoing entitlement under section 12(5)(b) of the Statutory Accident Benefits Schedule.
The arbitrator found that the applicant suffered from chronic pain syndrome resulting from the accident, which continuously prevented him from engaging in any employment for which he was reasonably suited by education, training, or experience, including the alternative position of a service advisor.
The arbitrator ordered the insurer to pay weekly income benefits from the date of termination, along with interest and arbitration expenses.
Arbitration dismissed and expenses awarded to insurer after applicant failed to attend the hearing.
The applicant sought ongoing weekly income benefits following a motor vehicle accident but failed to attend the arbitration hearing.
The arbitrator proceeded in his absence under the Statutory Powers Procedure Act.
The applicant failed to meet his burden of proof, and the arbitration was dismissed.
The arbitrator found the proceeding to be an abuse of process and awarded the insurer $2,000 in expenses under the Insurance Act.
Insurer's limitation period defence fails due to lack of evidence that notice of refusal was mailed.
The insurer appealed an arbitration order finding that the insured's application for arbitration was not statute-barred.
The insurer argued that it had mailed a notice of refusal to pay benefits, triggering the two-year limitation period under the Insurance Act.
The Director of Arbitrations dismissed the appeal, finding insufficient evidence that the notice of refusal ever left the insurer's internal mail system or was received by the insured.
As a result, the limitation period had not commenced, and the insured's application was allowed to proceed.
Insured ordered to pay insurer's $1,000 assessment for abuse of process due to counsel's delay.
The insurer brought a motion to dismiss the insured's application for arbitration and for payment of its $1,000 assessment, arguing the insured's conduct constituted an abuse of process.
The insured's counsel had requested an adjournment but subsequently failed to coordinate a new hearing date or respond to numerous communications from the Commission and the insurer over a six-month period.
The arbitrator found that the unexplained failure to respect the Commission's procedures and respond to inquiries constituted an abuse of process.
However, the arbitrator declined to dismiss the arbitration, instead ordering the insured to pay the insurer's $1,000 assessment as a condition of proceeding with a rescheduled hearing.
Weekly income benefits reinstated but reduced by income available from part-time employment.
The applicant was injured in a motor vehicle accident and received weekly income benefits for 156 weeks.
The insurer terminated benefits, arguing she was capable of returning to work.
The arbitrator found that while the applicant suffered from chronic pain and was disabled from full-time work commensurate with her background, she was capable of part-time employment.
The arbitrator ordered the resumption of weekly income benefits but allowed the insurer to deduct 80% of the income available from part-time employment under section 15 of the Schedule.
The applicant was also awarded certain rehabilitation expenses, but her claim for a special award was dismissed.
Claim for ongoing accident benefits dismissed as applicant failed to prove accident caused delayed-onset neuropathic pain.
The applicant was injured in a motor vehicle accident in January 1991 and received statutory accident benefits until January 1995.
He subsequently developed severe neuropathic pain in his left leg and sought ongoing weekly income benefits and medical benefits.
The insurer disputed that the neuropathic condition was caused by the accident.
The arbitrator reviewed extensive medical evidence and testimony, noting a significant time lag between the accident and the onset of the leg pain.
The arbitrator concluded that the applicant failed to prove on a balance of probabilities that the accident caused the neuropathic condition.
Consequently, the claims for ongoing benefits were dismissed.
The insurer's claim for repayment was also dismissed, and the applicant was awarded his arbitration expenses.
Arbitrator dismisses claims for further accident benefits, finding no causal link to back injuries.
The applicant was injured in a motor vehicle accident and received statutory accident benefits.
He later developed intense lower back pain and was diagnosed with herniated discs, which he claimed were caused by the accident.
He also sought to include an unpaid $30,000 management fee in his pre-accident income calculation.
The arbitrator found that the medical evidence did not support a causal link between the accident and the back injuries, preferring the opinions of the insurer's and court-appointed experts.
The arbitrator also accepted the insurer's accounting expert's evidence that the unpaid management fee should not be included in the applicant's income.
The applicant's claims for further benefits were dismissed, though he was awarded his arbitration expenses.
Weekly income benefits calculated by averaging actual income over the four weeks preceding the accident; pre-existing conditions limited duration of benefits.
The applicant was injured in a motor vehicle accident and applied for statutory accident benefits.
At the time of the accident, he was receiving Workers' Compensation Benefits for a prior work-related injury.
The arbitrator determined that the applicant's gross weekly income must be calculated by averaging his actual income over the four-week period preceding the accident, without disregarding periods of unemployment.
The arbitrator also held that the Workers' Compensation Benefits received by the applicant must be deducted from the weekly income benefits payable by the insurer.
The applicant was awarded weekly income benefits for a limited period, as the arbitrator found that his ongoing inability to work after January 19, 1994, was substantially caused by pre-existing conditions not related to the motor vehicle accident.
Death benefits denied; child not a dependant where financially dependent on deceased's former spouse.
The appellant insurer appealed an arbitration decision finding that the deceased's daughter was entitled to death benefits as a dependant.
The daughter was financially dependent on her mother, who had previously been the common law spouse of the deceased but was no longer his spouse at the time of the accident.
The Director's Delegate allowed the appeal, holding that spousal status must be determined at the time of the accident.
Because the mother was no longer the deceased's spouse at the time of the accident, the daughter could not qualify as a dependant based on her financial dependence on the mother.
Application for ongoing accident benefits dismissed due to lack of credibility and lack of causal connection.
The applicant was struck by a car while crossing the street and claimed statutory accident benefits, including weekly income benefits and supplementary medical and rehabilitation benefits.
The insurer terminated weekly income benefits on December 31, 1992.
The arbitrator found the applicant lacked credibility due to numerous inconsistencies in his evidence regarding his pre-accident employment, medical history, and the accident itself.
The arbitrator accepted the evidence of the insurer's medical expert that the applicant's ongoing symptoms were related to aging and a pre-existing heart condition, not the motor vehicle accident.
The application for further benefits was dismissed, and the applicant was awarded only half of his arbitration expenses.
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