OFSCDRS 1997

The appellant insurer appealed an arbitration decision finding that the respondent claimant had a reasonable excuse for failing to notify the insurer of his accident benefits claim within 30 days of the accident.

The claimant's application was submitted nearly 18 months late due to a combination of personal problems and his first lawyer's failure to advance the claim.

The Director's Delegate upheld the arbitrator's finding that the claimant's personal circumstances constituted a reasonable excuse and that the insurer was not prejudiced by the delay, as the claimant's history of non-compliance meant earlier intervention would not have altered his recovery.

The appeal was dismissed.

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

The Insurer notified her of its intention to stop weekly benefits.

The Applicant initially requested an assessment at a designated assessment centre but later changed her mind after retaining counsel, opting instead for mediation.

She did not attend the scheduled assessment.

The Insurer brought a preliminary motion arguing she was precluded from proceeding to mediation and arbitration due to her failure to attend the assessment.

The Arbitrator held that the Applicant was not prevented from proceeding to arbitration, as she had a bona fide change of mind.

However, because her initial request for an assessment triggered the Insurer's obligation to continue paying benefits, she was required to repay the benefits received during that period on the basis of 'error'.

The Insurer's request for expenses was denied for lack of jurisdiction.

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

Allianz paid benefits but later disputed its obligation, arguing that General Accident was the priority insurer.

The insurers disputed whether Ontario Regulation 283/95, which mandates private arbitration for priority disputes, applied retroactively to this case.

The arbitrator held that the Regulation does not apply retroactively to disputes where the application for benefits was received before the Regulation came into force.

On the priority issue, the arbitrator found that the applicant's representative had made a valid election under section 268(5) of the Insurance Act to claim benefits from Allianz, and therefore Allianz was required to pay the benefits.

The appellant appealed an arbitration order finding that his application for arbitration regarding a claim for additional weekly benefits was time-barred.

The appellant argued that the insurer's Assessment of Claim was ambiguous and did not constitute a clear refusal, and that ongoing negotiations estopped the insurer from relying on the limitation period.

The Director's Delegate dismissed the appeal, upholding the arbitrator's finding that the insurer provided clear and unequivocal notice of its refusal to pay further weekly benefits and that the insurer's willingness to consider additional medical evidence did not waive the limitation period or mislead the appellant.

The Arbitrator issued a correction to a decision dated January 15, 1997, to amend an error in the name of the applicant's counsel.

The name 'Neil Sacks' was deleted and replaced with 'James R. Howie'.

The insured was injured in a motor vehicle accident and received weekly income benefits until the insurer terminated them at the three-year mark.

The insured applied for mediation within the two-year limitation period but did not apply for arbitration until more than two years after the benefits were terminated.

The arbitrator held that the limitation period applied on a rolling basis, barring only claims for periods ending more than two years before the application.

On appeal, the Director's Delegate reversed, holding that the two-year limitation period under section 281(5) of the Insurance Act runs from the insurer's refusal to pay benefits, not from the date each payment becomes overdue.

The insured's claim for further weekly income benefits was therefore entirely time-barred.

The applicant sought statutory accident benefits following two alleged motor vehicle accidents.

The insurer raised preliminary issues, arguing the first accident claim was settled, time-barred, and precluded by a civil proceeding.

The arbitrator dismissed these arguments, finding no final settlement, that the limitation period had not expired due to unclear termination notice, and that the civil action did not bar the arbitration.

Regarding the second accident, the arbitrator found the applicant was not an occupant of the vehicle and had misrepresented her involvement.

The insurer's request for repayment was reserved, but the applicant was ordered to pay a $1,000 assessment for an abuse of process regarding the second accident claim.

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

She subsequently missed two periods of work and claimed entitlement to weekly income benefits for those periods under section 12(5)(b) of the Statutory Accident Benefits Schedule.

The arbitrator found that the applicant failed to meet the burden of proving that her injuries continuously prevented her from engaging in any occupation or employment for which she was reasonably suited by education, training, or experience.

The claim for benefits was dismissed, but the applicant was awarded her arbitration expenses.

The Arbitrator issued a correction to a decision originally dated January 15, 1996.

The date was a typographical error and was corrected to January 15, 1997.

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

The insurer terminated her weekly income benefits after 156 weeks, arguing she was capable of returning to work.

The arbitrator found that the applicant suffered from chronic pain syndrome as a result of the accident and was continuously prevented from engaging in suitable employment.

The arbitrator ordered the insurer to pay ongoing weekly income benefits, denied the insurer's claim for repayment of an overpayment caused by its own error, and allowed the deduction of 80% of the applicant's actual post-accident earnings, but rejected the deduction of potential future income.

The appellant was severely injured in a motor vehicle accident and received weekly income benefits for three years.

After 156 weeks, the insurer terminated benefits on the basis that she was no longer continuously prevented from engaging in any occupation or employment for which she was reasonably suited.

The arbitrator found that while the appellant could not return to her pre-accident work as a self-employed computer consultant, she was capable of working in less complex roles within the computer industry.

On appeal, the Director's Delegate upheld the arbitrator's decision, finding no error in the conclusion that suitable, flexible employment was available to the appellant.

The applicant was injured in a motor vehicle accident and sought payment for a naturopathic treatment known as bovine extract under section 6 of the Statutory Accident Benefits Schedule.

The insurer denied the claim.

The arbitrator dismissed the claim, finding no reliable evidence that the experimental bovine therapy was reasonable or likely to benefit the applicant.

The arbitrator noted the lack of scientific support for the treatment and the applicant's failure to pursue active rehabilitation measures recommended by other assessors.

The appellant was injured in a motor vehicle accident and received weekly income benefits until the insurer terminated them based on surveillance evidence showing him working at his pizza business.

The arbitrator dismissed the appellant's claims for ongoing and increased weekly income benefits, replacement worker wages, and travel expenses.

On appeal, the Director's Delegate upheld the arbitrator's decision, finding ample evidence to support the conclusions and no errors of law.

The appeal was dismissed with no costs awarded.

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

Both Kingsway General and Lloyd's denied the claim, each arguing the other was responsible.

The preliminary issue was whether Kingsway General's policy was validly cancelled prior to the accident due to a missed premium financing payment to its related company, Kingsway Financial.

The arbitrator found that the premium financing arrangement was an attempt to circumvent the statutory notice requirements for cancellation under the Statutory Conditions.

The corporate veil was pierced, and the cancellation was deemed invalid for failing to provide statutory notice.

Kingsway General was held responsible for paying the benefits.

The appellant appealed an arbitration decision that denied him additional weekly income benefits following multiple motor vehicle accidents.

The appellant, representing himself on appeal, argued that the arbitration hearing should not have taken place because the issues were decided in a previous arbitration and he did not receive proper notice or full disclosure.

The Director's Delegate found no error in the arbitration process, noting that the previous arbitration only determined which issues could proceed and that the appellant's counsel at the hearing did not object to the proceedings or the admission of expert evidence.

The appeal was dismissed and the arbitration order was confirmed.

The applicants were injured in a motor vehicle accident and claimed statutory accident benefits from the insurer, including income replacement benefits, caregiver benefits, and taxi expenses.

The arbitrator found that the insurer was liable to pay benefits as there was no other available insurance.

However, the arbitrator dismissed the claims for income replacement benefits, finding that neither applicant had a legitimate contract of employment evidenced in writing at the time of the accident, and the female applicant did not suffer a substantial inability to perform the essential tasks of her pre-accident self-employment.

The claims for caregiver benefits and taxi expenses were also dismissed due to a lack of objective medical evidence and failure to prove the expenses were reasonably incurred.

The applicants were awarded one-third of their arbitration expenses.

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

A preliminary issue was raised regarding the interpretation of the phrase 'for any period in excess of 156 weeks' in section 13(8)(b) of the Statutory Accident Benefits Schedule.

The arbitrator held that the phrase means 156 weeks of disability, rather than a continuous 156-week period from the date of the accident or 156 weeks of benefits actually paid.

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

The insurer reduced her weekly income benefits to the minimum rate, and the applicant sought arbitration to claim a higher rate based on an alleged offer of employment.

The insurer raised a preliminary issue that the arbitration was barred by the two-year limitation period.

The arbitrator held that the limitation period was not triggered because the insurer's reduction of benefits was not a refusal to pay the benefit claimed.

On the substantive issue, the arbitrator found that the applicant was employed on an extended unpaid leave at the time of the accident and did not hold a legitimate offer of employment within the meaning of the Schedule.

The applicant was therefore entitled only to the minimum weekly benefit rate.

The appellant was injured in a motor vehicle accident and received weekly income benefits until the insurer terminated them, claiming he was no longer substantially unable to perform the essential tasks of his employment.

The appellant sought additional benefits, which were denied at arbitration.

On appeal, the Director's Delegate found no error in the arbitrator's assessment of the medical evidence, which included opinions from two physicians that the appellant was capable of returning to work.

The appeal was dismissed and the arbitration decision confirmed.

The applicant sought reinstatement of weekly income benefits following a minor single-vehicle accident.

The insurer terminated benefits based on medical reports and surveillance evidence showing the applicant performing physical tasks.

The arbitrator found the applicant lacked credibility, noting extensive pre-existing physical and psychological problems, including marital difficulties and prior injuries.

The arbitrator concluded the accident did not materially contribute to her ongoing issues and dismissed the claim for benefits.

Finding the arbitration to be an abuse of process, the arbitrator ordered the applicant to pay the insurer's $2,000 assessment fee.