OFSCDRS 1997

The applicant was rendered a quadriplegic in a motor vehicle accident and applied for statutory accident benefits from the insurer.

The insurer denied coverage, arguing its policy on the leased vehicle had expired months prior, and thus it was not an 'insurer' under the Insurance Act or O. Reg. 283/95.

The applicant brought a motion for interim benefits.

The arbitrator held that because the applicant asserted a contractual nexus and the insurer admitted to previously insuring the vehicle, the insurer was required to respond.

Under O. Reg. 283/95, the first insurer to receive an application must pay benefits pending the resolution of any priority dispute through private arbitration.

Finding an urgent need, the arbitrator ordered the insurer to pay specified interim medical and rehabilitation benefits.

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

She later sought to elect income replacement benefits instead.

The arbitrator found that the insurer's adjuster had negligently misrepresented the available benefits and failed to provide the required written explanation under section 59(2) of the Statutory Accident Benefits Schedule.

The insurer's failure to correct this misinformation led to the applicant's initial election.

The arbitrator ruled that the applicant was not bound by the deemed election provision and could now elect to receive income replacement benefits.

The applicant sought income replacement benefits and the cost of a replacement penile prosthesis following a motor vehicle accident.

The insurer terminated income benefits after medical assessments concluded the applicant was capable of returning to work as a limousine driver.

The arbitrator dismissed the claim for income benefits, finding the applicant's evidence of ongoing disability lacked objective medical support and his credibility was undermined by a failure to disclose pre-accident medical issues.

The claim for a replacement prosthesis was also dismissed, as the evidence indicated the device was malfunctioning prior to the accident.

The applicant was ordered to repay a $3,000 advance provided by the insurer for the prosthesis.

The Director's Delegate issued a correction to an appeal order dated May 2, 1997.

The correction amended a sentence in the first paragraph to clarify that the arbitrator granted the appellant his arbitration expenses, rather than his appeal expenses.

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

The insurer alleged that the applicant's request for arbitration was out of time.

The arbitrator found that the insurer's notices of refusal to pay benefits were not clear and unequivocal, lacked sufficient reasons, and were not properly communicated to the applicant.

Therefore, the limitation period did not begin to run, and the applicant's arbitration proceeding was commenced in time.

The Applicant sought ongoing weekly income benefits following a minor motor vehicle accident.

The Insurer terminated benefits after 10 months.

The Arbitrator found the Applicant's claims of disabling physical and psychological pain to be unsupported by objective medical evidence and contradicted by surveillance footage showing him engaging in normal activities without restriction.

The claim for ongoing benefits was dismissed.

The Applicant was awarded half of his arbitration expenses and the return of a $2,000 assessment fee, as the claim was not found to be frivolous or vexatious.

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

A priority dispute arose between General Accident and Lloyd's.

The arbitrator determined that Lloyd's was responsible for paying benefits because the applicant was a 'named insured' under the Lloyd's policy, whereas he was merely listed as a driver on an endorsement under the General Accident policy.

The arbitrator also determined the value of non-monetary benefits (lodging, food, and tobacco) provided by the applicant's employer to be included in his gross weekly income calculation, despite the applicant's failure to declare these benefits on his income tax returns.

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

The insurer terminated benefits after 156 weeks, arguing that the appellant's ongoing neuropathic leg pain was not caused by the accident.

An arbitrator dismissed the appellant's claim for ongoing benefits, preferring the medical evidence that a causal link was unlikely given the delayed onset of symptoms.

On appeal, the Director's Delegate upheld the arbitrator's decision, finding no error in the assessment of the expert medical evidence regarding causation.

The appeal was dismissed and no appeal expenses were awarded.

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

The insurer subsequently disputed his entitlement, arguing he was an employee entitled to workers' compensation benefits.

At a preliminary issue hearing, the arbitrator found the applicant failed to produce required corporate and financial documents, drawing adverse inferences against him.

The arbitrator concluded the applicant was entitled to workers' compensation benefits and had initiated a tort action primarily to claim accident benefits, thus excluding him from SABS coverage under s. 76.

The insurer's claim for repayment of over $109,000 in benefits was dismissed for lack of evidence of fraud or misrepresentation.

The applicant was ordered to pay the insurer's $2,000 assessment fee for commencing a frivolous arbitration.

The Arbitrator issued a correction to a previously released decision dated April 10, 1997.

A typographical error regarding the date until which the insurer paid weekly income benefits was corrected from September 5, 1993, to September 5, 1994.

The appellant, a teenager injured in a motor vehicle accident, appealed an arbitrator's decision denying her claim for ongoing weekly statutory accident benefits.

The appellant argued that she sustained a psychological or mental injury in the accident that continuously disabled her.

The arbitrator had concluded that the accident was not a significant factor in the development of her psychological condition, preferring the respondent's expert evidence over the appellant's.

On appeal, the Director of Arbitrations found that the arbitrator properly weighed the conflicting medical and psychological evidence, including the appellant's pre-existing behavioural issues and family circumstances.

The appeal was dismissed, and the arbitration order was confirmed.

The applicant sought to rescind a settlement agreement for statutory accident benefits two days after signing it, despite having signed a waiver of the two-day cooling-off period under the Settlement Regulation.

The arbitrator held that the Settlement Regulation is consumer protection legislation and there is an implied prohibition against contracting out of its provisions.

The settlement was properly rescinded.

The arbitrator declined to order immediate repayment of the $15,000 settlement funds, leaving that for the hearing arbitrator, but ordered the applicant to pay the insurer's $2,000 assessment fee as a condition of continuing the arbitration due to his failure to attempt to return the funds.

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

The appellant, who was self-represented on appeal, argued that he was denied a fair hearing because of inadequate interpretation services during the arbitration, particularly during his lawyer's closing submissions.

The Director's Delegate found that while there were minor interpretation issues, they did not affect the fairness of the hearing or result in an injustice.

The insurer's request for a special award on the basis that the appeal was frivolous or vexatious was denied, as the appellant's concerns were not groundless.

The appeal was dismissed and no expenses were awarded.

The applicant sought death benefits following the death of her partner in a motor vehicle accident, claiming they were married by native custom or that she was deemed a widow under the Indian Act, and that he was the customary adoptive parent of her daughter.

The arbitrator found that the relationship did not constitute a native marriage by custom, the declaration of widowhood under the Indian Act did not change her unmarried status for the purpose of the Insurance Act, and the deceased was not an adoptive parent.

The claims for death benefits were dismissed.

The insurer appealed an arbitration decision that refused to order the respondent to repay weekly income benefits under section 27 of the Statutory Accident Benefits Schedule.

The insurer argued that it paid the benefits through error because it mistakenly believed the respondent was on a temporary lay-off at the time of the accident.

The Director's Delegate dismissed the appeal, finding that the insurer did not pay the benefits through error, as it had calculated them properly based on the information provided and the prevailing case law at the time.

The Delegate affirmed that an innocent insured person should not be required to repay benefits due to a later reassessment based on new information or developing case law.

The Applicant was injured in a motor vehicle accident and sought statutory accident benefits, including weekly childcare and medical/rehabilitation benefits, after the Insurer terminated them.

The Arbitrator found the Applicant lacked credibility regarding her pre-accident activities and initial disability, denying weekly benefits for the period immediately following termination.

However, the Arbitrator accepted that a subsequent disc herniation and sciatica exacerbation were causally related to the accident, awarding weekly benefits for a limited period in 1995.

The Arbitrator also awarded various medical and rehabilitation expenses and ordered a $500 special award against the Insurer for unreasonably delaying certain payments.

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

The applicant sought arbitration for ongoing income replacement benefits and the cost of an orthopaedic mattress.

The arbitrator found the applicant lacked credibility, noting significant inconsistencies between his reported disability and surveillance evidence showing him working and performing physical tasks.

Relying on independent medical assessments, the arbitrator concluded the applicant did not suffer a substantial inability to perform the essential tasks of his employment.

The claims for ongoing benefits, the mattress, and arbitration expenses were dismissed.

The applicant was injured in a motor vehicle accident when struck as a pedestrian.

She received statutory accident benefits until the insurer terminated her weekly income benefits.

The applicant sought arbitration, claiming ongoing entitlement to weekly income benefits, supplementary medical benefits for expert reports, and a special award.

The arbitrator dismissed the claim for ongoing weekly income benefits, finding the applicant failed to establish on a balance of probabilities that her ongoing physical and psychological symptoms were causally related to the accident or that they substantially disabled her from returning to her pre-accident employment.

The claim for a special award was also dismissed.

However, the arbitrator awarded the applicant her expenses for the arbitration, including the costs of the medical reports.

The appellant insurer appealed an arbitration decision finding it responsible for paying statutory accident benefits to the claimant.

The claimant was injured while a passenger in a vehicle insured by the respondent insurer.

The claimant applied for benefits from the appellant insurer on the basis that she was the spouse of its named insured.

The arbitrator found that the claimant and the named insured had cohabited in a relationship of some permanence and were therefore spouses under the Insurance Act.

On appeal, the Director's Delegate upheld the arbitrator's finding, concluding that there was sufficient evidence to support the determination of cohabitation despite the parties maintaining separate residences.

The appeal was dismissed, with a new issue regarding policy interpretation reserved for further submissions.

The applicant, whose common-law spouse died in a motor vehicle accident, applied for arbitration claiming interest on a $10,000 dependent death benefit paid by the insurer.

The applicant argued interest should run from her initial April 1994 application for spousal death benefits, while the insurer maintained it only received the application for dependent benefits in March 1995.

The arbitrator found the initial application did not claim dependent benefits and the insurer paid interest for the correct period.

The claims for further interest and a special award were dismissed, but the applicant was awarded her expenses.