OFSCDRS 1998

The appellant insurer appealed an interim arbitration decision, arguing that the arbitrator should not continue to conduct the hearing due to a reasonable apprehension of bias.

The Director's Delegate allowed the appeal to proceed solely on the issue of whether the arbitrator could continue.

The Director's Delegate found that the combination of procedural confusion, the rulings made by the arbitrator, and the contentious nature of the preliminary hearing established a reasonable apprehension of bias.

The appeal was allowed, and it was ordered that the arbitration hearing must be conducted by a different arbitrator.

The applicant was injured when she fell on a TTC bus.

She applied for statutory accident benefits, including income replacement benefits and various medical and rehabilitation expenses.

The insurer terminated income replacement benefits based on a multidisciplinary DAC assessment.

The arbitrator found the applicant to be a poor historian prone to exaggeration and deceit, and preferred the evidence of the IME and DAC assessors over her treating physiatrist.

The claim for ongoing income replacement benefits was dismissed as the applicant failed to prove she was substantially unable to perform her duties as a housekeeper and nanny.

Claims for psychological treatment, massage therapy, a lumbosacral support, and some taxi fares were allowed, while the remaining claims were dismissed.

The applicant sought an assessment of expenses following the settlement of an arbitration for statutory accident benefits.

The arbitrator assessed legal fees and disbursements, applying the Legal Aid Tariff rate.

The arbitrator held there was no jurisdiction to award interest or a special award on arbitration expenses, as the relevant statutory provisions apply only to the payment of benefits.

The arbitrator also held that an expense assessment is an integral part of the arbitration process and awarded the applicant expenses for the assessment hearing itself.

The applicant was injured in a motor vehicle accident while a passenger in a car.

The insurer denied income replacement benefits, arguing the applicant was excluded under s. 30(2)(b) of the Statutory Accident Benefits Schedule because he knew or ought reasonably to have known the driver was operating the vehicle without the owner's consent.

The arbitrator found that the driver's father was the owner of the vehicle and had not consented to the driver's use.

However, the insurer failed to prove that the applicant knew or ought reasonably to have known of the lack of consent.

The exclusion did not apply, and the insurer was ordered to pay interim income replacement benefits.

The applicant applied for arbitration seeking income replacement benefits and reimbursement for an occupational therapy assessment following a motor vehicle accident.

Shortly after, the applicant's representative withdrew the application and ceased acting for him.

The applicant failed to respond to communications or attend the pre-hearing and the hearing regarding withdrawal conditions.

The arbitrator granted the withdrawal and ordered the applicant to pay the insurer's expenses of $600.32, finding that while the claim for the assessment was not necessarily frivolous, the applicant's failure to communicate or attend unnecessarily lengthened the proceeding.

The applicant, a 52-year-old bricklayer with limited English skills, was injured in a motor vehicle accident.

He applied for statutory accident benefits, claiming ongoing weekly income benefits beyond the 156-week mark, care benefits, and a special award.

The insurer argued he was capable of performing alternative sedentary work.

The arbitrator found that the applicant suffered from a combination of musculoskeletal injuries, mild brain injury, and psychological impairments that rendered him competitively unemployable.

The arbitrator awarded ongoing weekly income benefits and care benefits for the assistance provided by his family, but denied the claim for a special award.

The insurer appealed an arbitration decision awarding the respondent additional weekly income benefits and a special award.

The insurer argued the arbitrator erred in law by admitting oral testimony from the respondent's medical expert that went beyond his written reports, causing unfair surprise.

The Director's Delegate dismissed the appeal, finding that the expert's testimony regarding the respondent's medication and physical limitations was a reasonable amplification of his reports and the medical record.

Furthermore, the insurer's counsel did not object to the testimony at the hearing, chose to cross-examine the expert, and did not request an adjournment to call responding evidence, thereby waiving the right to claim procedural unfairness.

The applicant sought ongoing weekly income benefits and medical and rehabilitation benefits following a motor vehicle accident.

The insurer terminated benefits and sought repayment, alleging the applicant was involved in an insurance fraud scheme and had misrepresented his pre-accident and post-accident employment.

The arbitrator found the applicant entirely unreliable, noting he had pleaded guilty to fraud in relation to false employment confirmation forms.

The arbitrator concluded the applicant sustained only minor soft tissue injuries, was not disabled, and had been actively employed in auto body shops during the benefit period.

The application was dismissed, and the applicant was ordered to repay $27,600 in benefits obtained by fraud, plus interest, and to pay the insurer's $2,000 arbitration assessment.

The applicant, an assembly line worker, was struck by a van while crossing the street, sustaining a severe left knee injury.

The insurer paid income replacement benefits until July 1995, when it terminated them based on medical assessments suggesting she could return to work.

The applicant sought ongoing benefits up to the 104-week mark.

The arbitrator found that the applicant's job required prolonged sitting with her knee bent, which caused disabling pain and reduced concentration.

Preferring the evidence of the treating specialists over the insurer's assessor, the arbitrator concluded the applicant suffered a substantial inability to perform the essential tasks of her employment.

The claim for ongoing income replacement benefits was allowed, but the request for a special award was dismissed as the insurer's initial termination was based on medical reports available at the time.

The insurer appealed an arbitration order finding that the insured's application for arbitration was not time-barred.

The insurer had terminated the insured's weekly income benefits and provided oral, but not written, notice of its decision.

The Director's Delegate dismissed the appeal, holding that under the Insurance Act and the Statutory Accident Benefits Schedule, an insurer must provide written notice of a refusal to pay benefits to trigger the two-year limitation period.

The Director's Delegate also rejected the insurer's argument that the insured was estopped from relying on the lack of written notice, finding insufficient evidence that the insurer continued to rely on any agreement to forgo written notice.

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

The applicant applied for arbitration more than two years after the termination.

The insurer raised a preliminary issue that the application was statute-barred.

The applicant argued the limitation period did not begin because the notice of termination was sent to her lawyer, not to her personally, and was not clear and unequivocal.

The arbitrator found the notice was clear and that the insurer was entitled to rely on the lawyer's actual or ostensible authority to receive the notice.

The application was dismissed as untimely, but the applicant was awarded her arbitration expenses.

The applicant sought statutory accident benefits after walking into the open hatch of a parked mobile production studio vehicle.

The insurer denied benefits, arguing the incident was not an 'accident' under the Schedule.

The arbitrator applied the Amos test and found that the vehicle was being used as a mobile production studio, not an automobile, at the time of the incident.

The arbitrator concluded that the injuries did not result from the ordinary and well-known activities to which automobiles are put, and therefore the incident did not constitute an 'accident'.

The application was dismissed, but the applicant was awarded expenses.

The applicant sought interim income replacement and medical-rehabilitation benefits following a motor vehicle accident.

The insurer had terminated benefits, and the parties were unable to resolve their disputes through mediation.

The arbitrator found that the applicant established a probable case for entitlement to income replacement benefits and demonstrated financial urgency, awarding partial interim income replacement benefits at $235.74 per week.

The arbitrator also awarded interim benefits for housekeeping and transportation to medical appointments, but denied other requested medical and rehabilitation expenses, finding they were either past expenses or not urgently required.

The issue of a special award was reserved for the main arbitration hearing.

The applicant, a 70-year-old pedestrian, was struck by a vehicle and sustained orthopaedic injuries.

She sought statutory accident benefits for attendant care and other services provided by her daughter.

The insurer disputed the quantum and causation, arguing the applicant's progressive dementia was not accident-related.

The arbitrator found the dementia was not caused by the accident but awarded attendant care and housekeeping benefits based on the applicant's accident-related orthopaedic impairments, increasing from 7 to 14 hours per week over time, payable at the minimum wage rate.

Claims for a special award were dismissed due to the applicant's misrepresentations regarding her daughter's lost income.

The applicant sought a death benefit following the death of his son in a motor vehicle accident.

The insurer denied the claim on the basis that the applicant failed to apply for benefits within the two-year limitation period and that the deceased was not a dependant.

The arbitrator held that the applicant was precluded from proceeding to arbitration because he failed to submit an application within two years of the accident, and that section 129 of the Insurance Act did not provide relief from forfeiture for this failure.

Furthermore, the arbitrator found that the deceased, a university student whose parents were divorced and shared his expenses equally, was not principally dependent for financial support on the applicant.

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

The insurer terminated benefits on the basis that the applicant no longer suffered from a disability.

The applicant applied for arbitration, seeking ongoing weekly income benefits and a special award.

The arbitrator found that the applicant suffered from chronic pain in her neck and shoulders that prevented her from returning to her pre-accident employment as a stamp examiner or any other suitable factory work.

The arbitrator ordered the insurer to pay ongoing weekly income benefits and interest, but declined to order a special award, finding that the insurer's decision to terminate benefits to test the applicant's subjective complaints of pain was not unreasonable.

The appellants were injured in a motor vehicle accident and received weekly income benefits for 156 weeks before the insurer terminated them.

More than two years after the termination, the appellants applied for mediation and subsequently arbitration.

The arbitrator dismissed the arbitration, finding the claims were time-barred.

On appeal, the Director's Delegate upheld the arbitrator's decision, applying binding precedent that the two-year limitation period begins to run upon the insurer's refusal to pay, thereby rejecting the appellants' 'rolling time limit' argument.

The applicant was injured in a motor vehicle accident and applied for arbitration after a dispute over weekly income benefits.

He subsequently disappeared, failing to attend the pre-hearing or the hearing, and failing to comply with production orders.

The arbitrator found that the applicant had constructively withdrawn his application and that his conduct amounted to an abuse of process.

The application was stayed, and the applicant was ordered to pay the insurer's $2,000 assessment fee and $500 in expenses.

The applicant was injured in a rear-end motor vehicle accident and sought ongoing income replacement benefits, which the insurer terminated.

The arbitrator found that the applicant was substantially unable to perform the essential tasks of his employment due to accident-related low back pain, which was compounded by a pre-existing knee condition and psychological factors.

The arbitrator also held that the insurer failed to comply with the mandatory termination notice procedures under section 64 of the Statutory Accident Benefits Schedule, depriving the applicant of the opportunity to request a DAC assessment.

As a result of the insurer's non-compliance and unreasonable withholding of benefits, the applicant was awarded ongoing income replacement benefits and a $5,000 special award.

The applicant was injured in a motor vehicle accident and applied for statutory accident benefits from Kingsway, which denied coverage claiming the policy was cancelled.

The applicant then applied to Pafco, which paid some benefits but asserted Kingsway was the responsible insurer.

The applicant commenced arbitration against Kingsway at the Financial Services Commission of Ontario (FSCO).

Kingsway brought a motion to dismiss the arbitration, arguing that the dispute was essentially a priority dispute between insurers governed by O. Reg. 283/95, which must be resolved through private arbitration.

The arbitrator agreed, finding that the core issue was which insurer was responsible for paying benefits, not the applicant's entitlement to specific benefits.

Therefore, the issue of whether a valid policy existed between the applicant and Kingsway was outside the jurisdiction of a FSCO arbitrator.