OFSCDRS 1997

The applicant was injured in a motor vehicle accident and sought payment for rehabilitation services provided by Trauma Services.

The insurer refused to fund further services and raised a preliminary issue, arguing that the arbitrator lacked jurisdiction because the service provider, not the insured, was the real applicant.

The arbitrator found that the applicant had not assigned her right to commence arbitration but had merely authorized the service provider to represent her and deal directly with the insurer.

The arbitrator concluded she had jurisdiction to hear the claim.

The appellant insurer appealed an arbitrator's decision finding it liable to pay statutory accident benefits to the respondent, who was injured while driving a rented taxicab.

The respondent had a personal vehicle insured with the appellant but was not a named insured on the taxicab's fleet policy.

The appellant argued that its policy excluded coverage for vehicles used as taxicabs.

The Director's Delegate dismissed the appeal, holding that the broad definition of 'insured person' in the Statutory Accident Benefits Schedule prevailed over the exclusions in the standard owner's policy.

Furthermore, the respondent was not a named insured under the taxicab's policy for the purposes of the priority rules in section 268 of the Insurance Act.

The claimant was injured while driving a taxicab insured by Simcoe & Erie.

He also owned a personal vehicle insured by State Farm.

State Farm argued it was not liable to pay statutory accident benefits because its policy excluded coverage while the automobile was used as a taxicab.

The Director's Delegate held that the broad definition of 'insured person' in the Statutory Accident Benefits Schedule prevailed over the exclusionary language in the standard Owner's Policy.

Under the priority rules in section 268(2) of the Insurance Act, the claimant was required to claim benefits from State Farm, the insurer of his personal vehicle, despite the accident involving a taxicab.

The applicants were injured in a motor vehicle accident and applied for statutory accident benefits.

They commenced a civil proceeding for treatment expenses and an arbitration for weekly benefits.

The insurer brought a preliminary motion to require the applicants to discontinue the civil proceeding and have all issues determined in the arbitration, relying on recent amendments to the Insurance Act.

The Arbitrator found that the amendments to section 282(3) were substantive and did not apply retrospectively.

Applying the pre-amendment provisions, the Arbitrator held that the applicants were entitled to pursue distinct claims in different forums, as the issues were capable of being determined independently without risk of contradictory findings.

The insurer's motion was dismissed.

The Applicant claimed statutory accident benefits following two alleged motor vehicle accidents.

In a previous decision, the arbitrator found the Applicant was not involved in the second accident and had made a serious misrepresentation to the Insurer.

The Insurer sought repayment of benefits paid after the second accident and a further assessment for the first accident claim.

The arbitrator dismissed the request for a further assessment, finding the first accident claim was not frivolous or vexatious simply because it was dismissed for failure to pay an initial assessment.

However, the arbitrator ordered the Applicant to repay $122,151.21 in benefits relating to the second accident, finding she materially contributed to the overpayment through her misrepresentation.

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

The insurer terminated benefits after 156 weeks, arguing the applicant was not continuously prevented from engaging in suitable employment.

The arbitrator found the applicant was substantially unable to perform his pre-accident work as a tile setter.

However, the arbitrator concluded there were suitable alternative occupations available, specifically a cashier position following a work conditioning program.

The arbitrator also allowed the applicant to recalculate his pre-accident income using the completion method of accounting, which increased his weekly benefit to the $600 maximum.

The applicant was awarded outstanding benefits up to the date he would have completed the work conditioning program, plus interest.

The applicant was injured in a motor vehicle accident just before starting a new job as a general labourer for a demolition company.

The insurer terminated his weekly income replacement benefits based on a Designated Assessment Centre report concluding he could return to work.

At arbitration, the arbitrator found that the DAC assessor failed to properly consider the specific, heavy physical demands of the applicant's prospective job, which included repeatedly swinging a sledgehammer and lifting up to 50 pounds.

The arbitrator concluded the applicant continued to suffer a substantial inability to perform the essential tasks of his employment and ordered the insurer to pay income replacement benefits for the disputed period, along with interest and expenses.

The Applicant was injured in a motor vehicle accident while riding a bicycle and received weekly income benefits until July 18, 1994.

She applied for ongoing benefits under section 12(5)(b) of the Statutory Accident Benefits Schedule, claiming she was continuously prevented from engaging in any occupation reasonably suited to her education, training, or experience.

The arbitrator found that while the Applicant suffered a permanent moderate restriction in her right elbow, she had the necessary skills and physical ability to work as a retail sales clerk or restaurant hostess.

The claim for ongoing weekly income benefits and a special award was dismissed, but the Applicant was awarded her arbitration expenses.

The applicant, a taxi driver, was stabbed by a passenger while waiting to be paid his fare.

He applied for statutory accident benefits, but the insurer denied the claim on the basis that the injuries were not caused by an 'accident' as defined in the Schedule.

The arbitrator applied the two-part test from Amos and found that the applicant was engaged in the ordinary use and operation of a motor vehicle at the time of the assault, and that there was a direct causal link between the use and operation of the taxi cab and the injuries.

The arbitrator concluded that the applicant was injured as a result of an accident and is entitled to proceed to arbitration.

The applicant was injured in a motor vehicle accident and received statutory accident benefits as well as CPP disability benefits.

The insurer argued that the parties had previously reached a binding settlement that CPP benefits were deductible, and alternatively, that CPP benefits are payments for loss of income and thus deductible under the Schedule.

The arbitrator found that no binding settlement was reached as there was no consideration given for the applicant's prior acknowledgement of the state of the law.

Furthermore, following appellate authority, the arbitrator held that CPP disability benefits are non-indemnity payments triggered by disability, not payments for loss of income, and therefore are not deductible from the applicant's gross weekly income.

The applicant sought 'other disability benefits' following a motor vehicle accident, claiming a complete or partial inability to carry on a normal life due to soft tissue injuries and severe heart and lung problems.

The insurer argued the applicant's disability resulted from pre-existing medical conditions.

The arbitrator found that the applicant's atrial fibrillation and respiratory issues were a natural progression of his pre-existing conditions and not caused by the accident.

However, the arbitrator concluded that the applicant did suffer soft tissue injuries in the accident that caused a partial inability to carry on a normal life for a limited period.

The applicant was awarded other disability benefits from March 22, 1994, to December 15, 1994.

The appellant appealed an arbitration decision denying his claims for statutory accident benefits, including housekeeping, medication, chiropractic expenses, a whirlpool spa, and weekly income benefits, as well as a special award and arbitration expenses.

The Director's Delegate dismissed the appeal, finding no unfairness in the arbitration process and agreeing with the arbitrator that there was insufficient medical evidence to support the appellant's claims.

The Delegate also confirmed that business losses and replacement labour costs are not payable as weekly income benefits or rehabilitation expenses under the Schedule.

No appeal expenses were awarded to either party.

The insurer sought to enforce a previous arbitration decision ordering the applicant to repay weekly benefits and physiotherapy payments, but the exact amounts were not specified.

The hearing was reconvened to determine the amounts.

The applicant did not dispute the amounts but requested the hearing be reopened to order her family physician and the physiotherapy clinics to repay the amounts instead, alleging they were responsible for the misrepresentations.

The arbitrator dismissed the request, finding no statutory authority to vary the final decision or to make orders against non-parties, and declined to exercise discretion to reopen the hearing.

The appellant appealed an arbitrator's decision denying her ongoing weekly benefits following a motor vehicle accident.

The arbitrator had found that the appellant's ongoing pain did not substantially disable her from performing her normal and essential tasks, basing this largely on an unfavourable assessment of her credibility.

On appeal, the Director's Delegate held that there was no basis to interfere with the arbitrator's credibility findings or evaluation of the evidence.

The appeal was dismissed, and the appellant was denied her appeal expenses.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits, including income replacement benefits, physiotherapy expenses, and the cost of a psychological assessment.

The insurer terminated benefits, arguing the applicant could return to his work as a piece-work upholsterer.

The arbitrator found that the applicant suffered from post-traumatic stress disorder and residual physical problems that substantially disabled him from performing the high-speed, repetitive tasks of his employment.

The arbitrator ordered the insurer to pay the claimed benefits, along with a special award under section 282(10) of the Insurance Act for unreasonably withholding payments.

The appellant insurer appealed an arbitration decision that found the respondent insured was entitled to ongoing weekly income benefits after the 156-week mark.

The insurer argued the arbitrator erred in finding that the respondent could not work as a locksmith without an apprenticeship and that working as a security guard was not a suitable alternative occupation.

The Director's Delegate dismissed the appeal, finding no error in the arbitrator's assessment of the expert evidence or the conclusion that the respondent lacked the education, training, or experience to engage in the suggested occupations without further retraining.

The applicant was injured in a motor vehicle accident and received statutory accident benefits, which the insurer terminated after three years.

She applied for arbitration seeking reinstatement of weekly benefits and homemaker services.

The arbitrator found that while the applicant suffered from a significant mobility impairment and chronic pain that justified the reinstatement of 12 hours per week of homemaker services, her disability was not so pervasive as to continuously prevent her from engaging in substantially all of her usual activities.

Therefore, the claim for ongoing weekly benefits was dismissed.

The applicant was awarded her expenses for the arbitration.

The appellant was injured in a motor vehicle accident in the course of his employment.

He initially received statutory accident benefits, then elected to receive workers' compensation benefits, and later re-elected to pursue a tort action and re-applied for accident benefits.

The arbitrator held that the appellant did not meet the conditions for receipt of statutory accident benefits under section 21 of the Statutory Accident Benefits Schedule because he had already received workers' compensation benefits.

The Director's Delegate dismissed the appeal, confirming that the appellant was excluded from receiving further accident benefits.

The Delegate also rejected the appellant's argument that a binding settlement had been reached, finding that the insurer's settlement offer expired when the arbitrator's decision was issued.

The applicant was injured in a motor vehicle accident and received statutory accident benefits until the insurer terminated them, alleging she failed to follow through with rehabilitation recommendations.

The applicant sought arbitration for weekly income benefits, rehabilitation benefits, and a special award.

The arbitrator found that the applicant was disabled from returning to her pre-accident employment as a bar-maid, noting the insurer's experts relied on a flawed job description.

The arbitrator also found the applicant was continuously disabled from engaging in any occupation for which she was reasonably suited by education, training, or experience.

The applicant was awarded weekly income benefits and partial rehabilitation benefits for a functional assessment and work trials, but the claim for a special award was dismissed.

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

The applicant applied for arbitration.

At a pre-hearing, the insurer requested that the applicant attend independent medical examinations by a psychiatrist and a physiatrist under section 23(2) of the Schedule.

The applicant refused, arguing the requests were unreasonable given previous examinations.

The arbitrator found the requests reasonable because the insurer had little current medical information, the applicant's condition was evolving, and over a year and a half had passed since her last insurer examinations.

The applicant was ordered to attend, and the insurer was ordered to provide the resulting reports at least four weeks before the arbitration hearing.