OFSCDRS 1997

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

The Insurer refused to pay income replacement benefits, alleging the Applicant failed to disclose that her 21-year-old son was a licensed driver living in the household, which would have resulted in a substantially higher premium.

The Arbitrator found that the Applicant knowingly and intentionally failed to disclose material facts to avoid a higher premium.

Consequently, the Applicant was excluded from receiving income replacement benefits under section 58(3)(a) of the Schedule, and her application for arbitration was dismissed.

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

The insurer refused to pay income replacement benefits, alleging the applicant made a material misrepresentation regarding the ownership and use of the insured vehicles, relying on section 58(3)(a) of the Statutory Accident Benefits Schedule.

The arbitrator found that while misrepresentations were initially made, subsequent amendments to the policy prior to the accident rendered them immaterial to the risk at the time of the accident.

The insurer was therefore not entitled to rely on the exclusion to deny benefits.

The applicant, a taxi driver, was injured when pinned between two vehicles.

He claimed ongoing weekly income benefits, alleging chronic pain and depression prevented him from working.

The insurer terminated benefits after medical assessments indicated he could return to work.

The arbitrator dismissed the claim for ongoing benefits, finding the applicant lacked credibility, exaggerated his symptoms, and had been working covertly at his brother's store, as revealed by surveillance evidence.

The medical opinions supporting disability were rejected as they relied on the applicant's unreliable subjective reporting.

The applicant was awarded one-third of his expenses.

The applicant was injured in a motor vehicle accident and sought various supplementary medical and rehabilitation benefits, a special award, and arbitration expenses.

The arbitrator held that issues not previously mediated could not be raised without the insurer's consent.

The claims for transportation, medication, orthopaedic shoes, and home maintenance expenses were dismissed because the applicant failed to sufficiently substantiate that they were reasonably and necessarily required as a result of the accident.

The claims for a special award and arbitration expenses were also dismissed.

The applicant, who suffered serious injuries in a motor vehicle accident, sought funding for a MacIntosh laptop computer to assist with his university computer science studies as a rehabilitation measure under section 40 of the Statutory Accident Benefits Schedule.

The insurer agreed a computer was needed but argued an IBM-compatible desktop was sufficient.

The arbitrator found that a laptop was reasonably required due to the applicant's physical limitations, but agreed with the insurer's expert that an IBM-compatible machine was adequate for his coursework.

The arbitrator also granted a special award of 25% under section 282(10) of the Insurance Act, finding that the insurer unreasonably delayed providing the computer and failed to cooperate with the applicant's rehabilitation efforts.

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

More than two years later, the applicants applied for mediation and subsequently arbitration.

The insurer argued the application was barred by the two-year limitation period under section 281(5) of the Insurance Act.

The applicants argued for a 'rolling limitation period' based on prior case law.

The arbitrator held that she was bound by a Director's Delegate decision which rejected the rolling limitation period, and therefore dismissed the application for arbitration as out of time.

The applicant was struck by an automobile while riding his bicycle and claimed statutory accident benefits, including other disability benefits (ODBs), medication, and transportation expenses.

The insurer terminated ODBs and argued the arbitration was barred because the applicant had previously commenced a tort action.

The arbitrator held that the Insurance Act does not preclude concurrent arbitration and court actions.

On the merits, the arbitrator found the applicant failed to establish a partial or complete inability to carry on a normal life, denying ongoing ODBs.

Claims for medication expenses were denied for lack of proof, but $140 for transportation expenses to medical appointments was awarded.

The applicants sought statutory accident benefits following the death of their son in a motor vehicle accident.

The deceased was an uninsured passenger in an uninsured vehicle.

The parents claimed the deceased was their dependant, which would make their insurer, Co-operators, liable to pay benefits.

Alternatively, they claimed they were dependent on him for care due to their deafness.

The arbitrator found that the deceased was not principally dependent on his parents for financial support at the time of the accident, as he was employed and living with his spouse and child.

Furthermore, the parents were not principally dependent on the deceased for care, as they were capable of independent living despite relying on him for sign language interpretation.

The claims for death benefits were dismissed, and the Motor Vehicle Accident Claims Fund was found responsible for paying the undisputed benefits to the deceased's spouse and child.

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

The insurer terminated weekly benefits on June 25, 1994.

The applicant applied for arbitration in August 1996.

The insurer raised a preliminary issue that the application was made beyond the two-year limitation period prescribed in the Insurance Act.

The arbitrator found that the insurer had given clear and unequivocal notice of its refusal to pay further weekly benefits in June 1994.

As the application was received more than two years after the refusal, it was out of time and could not proceed.

The insurer's request for an award for a frivolous or vexatious proceeding was denied.

The Applicant claimed $50,000 in spousal death benefits following the death of his alleged spouse in a motor vehicle accident.

The Insurer denied the claim on the basis that the Applicant and the deceased were not spouses, as the Applicant had moved out of their shared residence more than a year prior to the accident.

The Arbitrator found that the parties did not share a joint intention to separate temporarily, nor did they maintain an integrated relationship characterized by financial interdependence or shared household responsibilities.

The application for death benefits was dismissed, though the Applicant was awarded reasonable expenses for the hearing.

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

The insurer refused to pay certain invoices for rehabilitation services, and mediation failed.

The applicant subsequently signed a full and final release settling her claims for a lump sum.

She later applied for arbitration to claim the disputed rehabilitation expenses.

The arbitrator held that the release was a valid agreement that finally disposed of the claim, precluding the applicant from commencing arbitration.

Finding the arbitration to be an abuse of process, the arbitrator denied the applicant's expenses and ordered her to pay the insurer's assessment fee.

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

The applicant applied for arbitration more than two years after the insurer's refusal to pay further benefits.

The arbitrator held that the application was barred by the two-year limitation period in section 281(5) of the Insurance Act, following a binding decision of the Director's Delegate, despite the applicant's arguments that the limitation period should be interpreted as a rolling one.

The applicant was awarded expenses for raising worthwhile arguments.

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 more than two years after the insurer's refusal to pay ongoing benefits.

The applicant failed to attend the hearing.

The arbitrator proceeded in the applicant's absence and held that the applicant was barred from proceeding to arbitration for ongoing weekly income benefits due to the expiry of the two-year limitation period under the Insurance Act.

However, the applicant was not barred from arbitrating the quantum of the weekly benefits previously paid, as the insurer had not provided a proper notice of refusal regarding the amount.

The applicant was injured in a motor vehicle accident and claimed statutory accident benefits for a Kenko Sleep System (a magnetic mattress and pillow) costing $1,607.70.

The insurer denied the claim, arguing the device was experimental and not a medical device.

The arbitrator found that while the system qualified as a medical device under the Schedule, the applicant failed to prove it was a reasonable and necessary treatment for her accident-related impairment.

The medical evidence did not support the therapeutic value of the device for her soft tissue injuries.

The application for arbitration was dismissed, and no expenses were awarded.

The applicant, a restaurant cook, was injured in a motor vehicle accident and received income replacement benefits until the insurer terminated them.

The applicant claimed he remained disabled due to dizziness caused by the accident.

The arbitrator accepted the uncontradicted medical evidence of an otolaryngologist who diagnosed a post-traumatic labyrinthine concussion.

Finding that the applicant's dizziness prevented him from performing the demanding and hazardous tasks of a cook in a busy kitchen, the arbitrator concluded the applicant was substantially unable to perform his essential tasks.

The insurer was ordered to pay income replacement benefits for the disputed period, along with interest and expenses.

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

The applicant sought arbitration for ongoing income replacement benefits, an education disability benefit, housekeeping expenses, and a special award.

The arbitrator found that the accident materially contributed to the applicant's impairment, which included fibromyalgia and depression, rendering her substantially unable to perform the essential tasks of her demanding pre-accident managerial employment.

The applicant was awarded ongoing income replacement benefits with interest.

Claims for education and housekeeping benefits were dismissed for lack of evidence and failure to meet statutory requirements.

The issue of a special award was deferred to a subsequent hearing.

The appellant insurer appealed an arbitrator's decision finding that the respondent suffered psychological injuries as a result of an "accident" under the Statutory Accident Benefits Schedule.

The respondent, a limousine driver, was forced at gunpoint by a passenger to drive his vehicle for 45 minutes before being ordered out.

The Director of Arbitrations applied the two-part test from Amos v. Insurance Corp. of British Columbia and found that the respondent was engaged in the ordinary use of his vehicle, and that the forced operation of the vehicle at gunpoint indirectly caused his psychological injuries.

The appeal was dismissed and the arbitration order confirmed.

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

The insurer terminated the benefits, and the applicant requested a Designated Assessment Centre (DAC) assessment.

The parties postponed the assessment for settlement discussions, but when those failed, the insurer refused to arrange the DAC assessment or reinstate benefits, arguing the applicant had waived his rights.

The arbitrator found that the insurer egregiously breached section 64 of the Statutory Accident Benefits Schedule by failing to continue benefits pending the DAC assessment.

The arbitrator ordered the insurer to reinstate the applicant's income replacement benefits with interest, finding the breach alone justified the interim award, and alternatively, that the applicant met the threshold criteria for interim benefits.

The appellant, a high school student, was injured in a motor vehicle accident before starting a summer job.

The insurer paid weekly income benefits based on the prospective job's earnings for the duration of the summer contract, but reduced the benefits thereafter.

The Director's Delegate allowed the appeal, holding that under the Statutory Accident Benefits Schedule, once a person qualifies for benefits based on a definite job offer, the gross weekly income calculated from that contract establishes the benefit rate for the entire duration of the disability, not just the term of the contract.

The applicant was injured in a motor vehicle accident and sought ongoing weekly caregiver benefits, as well as costs for medical devices, housekeeping services, and a case manager.

The insurer had terminated caregiver benefits.

The arbitrator found that the applicant suffered a psychological impairment resulting from the accident, including depression and a driving phobia, which caused a partial inability to carry on a normal life.

The arbitrator awarded ongoing caregiver benefits, the costs of a massager and an orthopaedic mattress, and partial housekeeping expenses, but denied the claim for a case manager.