OFSCDRS 1997

The applicant was injured in a motor vehicle accident and applied for statutory accident benefits from Lloyd's, the insurer of the other vehicle, and later from Traders, his estranged wife's insurer.

Traders denied the claim as it was made outside the two-year limitation period.

The arbitrator held that the applicant was precluded from proceeding against Traders due to the late notice, and that the discoverability rule did not apply to extend the time limit.

The arbitrator also found that Lloyd's was not responsible for paying benefits because the applicant had recourse against Traders at the time of the accident, and Lloyd's was not estopped from denying coverage.

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

The insurer terminated benefits, arguing the applicant did not meet the test for continued entitlement.

The applicant sought reinstatement, claiming inability to work due to chronic pain and fibromyalgia.

The arbitrator found that the applicant's subsequent fall and worsening condition were related to the accident.

Accepting the medical evidence of fibromyalgia, the arbitrator concluded the applicant was unable to perform any suitable job and ordered the reinstatement of weekly income benefits.

The request for a special award was denied as the insurer had not unreasonably withheld payments.

The Director's Delegate issued a correction to an appeal decision dated February 27, 1997.

The correction amended a typographical error in the first paragraph of the reasons for decision, changing the stated date of the appellant's automobile accident from September 1, 1993, to the correct date of September 10, 1993.

The applicant applied for statutory accident benefits following a motor vehicle accident.

The insurer alleged the claim was fraudulent.

At the commencement of the arbitration hearing, the self-represented applicant sought to withdraw her dispute.

The arbitrator permitted the withdrawal but found the applicant's failure to provide advance notice of her intention to withdraw constituted an abuse of process.

The applicant was ordered to pay the insurer $2,000 for the assessment fee.

The insurer's claim for arbitration expenses was denied as the relevant statutory amendments did not apply retroactively.

The appellant's husband was killed in a motor vehicle accident while in the course of his employment.

The appellant and her children received death benefits from the respondent automobile insurer, and subsequently received survivor's benefits from the Workers' Compensation Board.

The insurer demanded repayment of the death benefits under section 20 of the Statutory Accident Benefits Schedule, which precludes payment where the insured person is entitled to workers' compensation benefits.

The Director's Delegate upheld the arbitrator's decision that section 20 applies to prevent double recovery, even though the workers' compensation benefits were payable to the survivors rather than the deceased insured person.

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

Following a pre-hearing discussion, the lawyers for the parties negotiated a settlement.

The Insurer sent a release and disclosure notice to the Applicant's lawyer, but the Applicant never signed the release.

The Insurer argued a binding settlement was reached.

The Arbitrator held that under the Settlement Regulation, a binding settlement requires the insured to confirm acceptance after receiving the mandatory disclosure notice.

Since the Applicant did not sign the release or otherwise confirm acceptance, and later communicated her rejection, no binding settlement was entered into.

The Applicant was permitted to proceed to arbitration.

The applicant was injured in a motor vehicle accident and applied for statutory accident benefits from Allstate, the insurer of the vehicle that struck her.

Allstate argued that the applicant was the spouse of her roommate, who was insured by Belair, and therefore Belair should pay the benefits.

The arbitrator applied the Molodowich factors and found that the applicant and her roommate were merely friends sharing accommodation, not spouses living in a conjugal relationship.

Allstate was found responsible for paying the applicant's statutory accident benefits.

The applicant applied for statutory accident benefits after a motor vehicle accident in his employer's parking lot.

The insurer denied the claim, arguing the applicant was entitled to workers' compensation benefits.

At mediation, the parties reached a tentative agreement, but the insurer later refused to pay upon learning the Workers' Compensation Board had allowed the applicant's claim for health care benefits while denying lost time benefits.

The Arbitrator held that the mediation agreement was based on a misunderstanding and was not binding.

Furthermore, because the applicant was entitled to receive some workers' compensation benefits, section 20 of the Statutory Accident Benefits Schedule precluded him from receiving accident benefits.

He was also not entitled to interim benefits under section 21 because he had elected to receive workers' compensation benefits and the WCB had already determined his entitlement.

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

She applied for arbitration claiming ongoing weekly income benefits, medical expenses, and a special award.

The arbitrator found that the applicant suffered a substantial inability to perform the essential tasks of her employment as a dispatcher/cashier due to ongoing physical and psychological injuries, including right arm weakness, anxiety, and depression caused by the accident.

The arbitrator awarded weekly income benefits for the disputed two-year period.

Claims for nutritional counselling, meal replacements, and a special award were dismissed due to insufficient evidence.

The arbitrator also ruled that the new expense provisions under the Automobile Insurance Rate Stability Act did not apply retroactively, denying the insurer's claim for expenses and awarding the applicant her expenses of the proceeding.

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

The Insurer terminated income replacement benefits on the basis that the Applicant was a resident of Ontario at the time of the accident but only held a Quebec driver's licence, and was therefore not authorized by law to drive under section 32 of the Highway Traffic Act.

The Arbitrator found that the Insurer presented substantial objective evidence proving the Applicant had been a resident of Ontario since 1993.

The Applicant's evidence to the contrary was found not credible.

Consequently, the Applicant was precluded from receiving income replacement benefits pursuant to section 58(1)(d) of the Schedule.

Despite this, the Arbitrator awarded the Applicant two-thirds of his arbitration expenses because the Insurer unnecessarily prolonged the hearing.

The Applicant sought ongoing weekly income benefits and medical/rehabilitation benefits following a rear-end motor vehicle accident.

The Insurer had terminated benefits based on surveillance evidence showing the Applicant performing heavy lifting, which contradicted his presentation during medical assessments.

The Arbitrator found the Applicant lacked credibility and that his ongoing complaints were primarily attributable to pre-existing obesity, severe sleep apnea, and degenerative back changes, rather than the accident.

The Applicant's claims for ongoing benefits and a special award were dismissed.

The Insurer's claim for repayment of benefits was also dismissed, as the Applicant did not materially contribute to the overpayment through error or fraud.

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

The insurer disputed her entitlement to income replacement benefits, arguing she was not substantially disabled and disputing the calculation of her post-accident business expenses.

The arbitrator found the applicant suffered a mild traumatic brain injury and was substantially disabled until October 1995.

The arbitrator allowed most of the applicant's post-accident business expenses, finding they were reasonably incurred to prevent a loss of revenue in her expanded business, but denied her claim for loss of profits.

The arbitrator also awarded various medical and rehabilitation benefits, including psychological counselling and a treadmill.

A special award of 35% was imposed against the insurer for unreasonably delaying and withholding benefits, particularly psychological counselling, despite recommendations from multiple assessors.

The Applicant sought to withdraw his Application for Arbitration for statutory accident benefits after realizing he had missed the two-year limitation period, intending instead to pursue a court action against his former solicitor for negligence and an alternate claim for benefits.

The Arbitrator permitted the withdrawal but found that commencing and then withdrawing the arbitration to pursue a better forum constituted an abuse of process.

Consequently, the Applicant was ordered to pay the insurer's $2,000 assessment fee, and prohibited from commencing another arbitration for the same benefits until the fee is paid.

The applicant was injured in a minor motor vehicle accident and sought statutory accident benefits for acupuncture, a TENS machine, an orthopaedic bed, and travel expenses.

The insurer denied the claims, arguing the symptoms were related to pre-existing conditions.

The arbitrator found the applicant lacked credibility, having intentionally withheld his pre-accident medical history from examining physicians and misrepresented his employment status.

The arbitrator concluded the applicant failed to prove the claimed expenses were reasonable, necessary, or caused by the accident.

The claims were dismissed, and neither party was awarded expenses.

The appellant insurer appealed an arbitrator's decision finding it responsible for paying the insured's statutory accident benefits.

The appellant also sought to vary the order to introduce fresh evidence regarding a commercial use exclusion, arguing the insured was carrying a passenger for compensation at the time of the accident.

The Director's Delegate dismissed the appeal and the application for variation, finding that the appellant failed to exercise due diligence in obtaining the evidence for the initial hearing and that the arbitrator reasonably concluded the insured had elected to claim benefits from the appellant.

The applicant, a self-employed farmer, was injured in a motor vehicle accident and received weekly income benefits from the insurer.

The insurer terminated benefits after 156 weeks, arguing the applicant did not meet the stricter test of disability under section 12(5)(b) of the Statutory Accident Benefits Schedule.

The arbitrator found the applicant was continuously prevented from engaging in suitable employment and remained entitled to benefits.

The arbitrator also accepted the applicant's accountant's calculation of gross weekly income, which treated the value of exchanged family labour as a ceasing business expense.

Finally, the arbitrator held that the insurer was not entitled to repayment of an initial overpayment, as the error resulted from the insurer's interpretation of the legislation rather than any material act or omission by the applicant.

The applicant was injured in a motor vehicle accident and claimed statutory accident benefits from two insurers, Royal and Coseco.

The insurers disputed priority.

The arbitrator determined that Ontario Regulation 283/95, which mandates private arbitration for priority disputes, does not apply retroactively to this case.

The arbitrator found that the applicant had chosen Coseco by submitting her first completed application for benefits to them, and therefore Coseco was liable to pay her claims.

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

The insurer refused to pay, and the applicant applied for arbitration.

The insurer raised preliminary issues regarding whether the applicant was precluded from arbitration for failing to submit a completed application for benefits (s. 59) and failing to attend insurer's examinations (s. 65).

The arbitrator found that the applicant substantially complied with the application requirement but failed to make himself reasonably available for the scheduled medical examinations without a reasonable explanation.

As a result, the applicant was precluded from commencing an arbitration proceeding.

The applicant was injured when she fell after descending from a bus.

She was knocked over by a crowd of students attempting to board the bus.

The insurer denied statutory accident benefits, arguing the incident did not involve the use or operation of an automobile.

The arbitrator found that the movement of persons onto a bus is integral to its use or operation, and that the flow of persons onto the bus caused the applicant to fall.

The arbitrator concluded the applicant was involved in an 'accident' as defined in the Schedule and is eligible for benefits.

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

The insurer terminated weekly income benefits, arguing the applicant was no longer disabled from returning to work.

The arbitrator found that the applicant suffered from chronic pain syndrome and remained continuously disabled from engaging in any occupation or employment for which he was reasonably suited by education, training, or experience.

The applicant's claim for a higher quantum of benefits was dismissed due to conflicting evidence regarding his pre-accident earnings.

The insurer was ordered to pay outstanding benefits at the original rate with interest, and the applicant was awarded his expenses of the arbitration.