OFSCDRS 1998

The Applicant was injured in a motor vehicle accident and claimed ongoing income replacement benefits.

The Insurer argued his condition was not caused by the accident and he was not motivated to return to work.

The Arbitrator found that the Applicant suffered continuous depression, reduced cognitive skills, and chronic pain as a result of the accident.

Due to these cognitive and physical disabilities, the Applicant suffered a substantial inability to perform the essential tasks of his job as a welder.

The Arbitrator ordered the Insurer to pay ongoing income replacement benefits and the expenses of the arbitration.

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

The Applicant sought arbitration for ongoing weekly income benefits, medical and rehabilitation benefits, and a special award.

The arbitrator found that the Applicant suffered from chronic pain and soft tissue injuries that prevented her from returning to full-time work, entitling her to ongoing weekly income benefits and specific rehabilitation benefits, including ergonomic equipment for a home office.

The arbitrator denied the Insurer's request for repayment of chiropractic expenses and denied the Applicant's request for a special award, finding the Insurer's actions were not unreasonable.

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

The insurer terminated benefits on the basis that she no longer met the post-156 week disability test.

An arbitrator dismissed her claim for ongoing benefits and a special award, finding insufficient medical evidence of disability and that the insurer acted reasonably.

On appeal, the Director's Delegate upheld the arbitrator's decision, finding no error in the assessment of the medical evidence or the conclusion that the appellant's failure to pursue recommended psychological counselling was her own responsibility.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for the cost of a multidisciplinary assessment and a subsequent treatment program provided by a rehabilitation facility.

The insurer disputed the necessity of the treatment and the reasonableness of the costs, and argued the arbitration was improperly brought by the facility rather than the insured.

The arbitrator found the arbitration was properly instituted.

On the merits, the arbitrator accepted that the applicant suffered from physical and psychological impairments, making the assessment and treatment plan reasonable in principle.

However, the arbitrator found the facility's billing practices to be highly excessive, redundant, and unreasonable.

The arbitrator significantly reduced the amounts payable for both the assessment and the treatment program, and declined to order a special award against the insurer.

The applicant was injured in a motor vehicle accident and received weekly income benefits until August 1994.

The insurer argued the applicant's request for arbitration was time-barred under subsection 281(5) of the Insurance Act, relying on an Assessment of Claim form dated July 26, 1994 as its notice of refusal.

The arbitrator found the form did not satisfy the requirements of subsection 24(8) of the Statutory Accident Benefits Schedule because it was self-contradictory, stating the claim was 'accepted in its entirety' while also referencing a final settlement, and failed to provide clear reasons for refusal.

Consequently, the limitation period was not triggered, and the applicant was permitted to proceed to arbitration.

The appellant appealed an arbitrator's refusal to award her arbitration expenses following a two-day hearing regarding her claim for a 'Kenko Sleep System'.

The arbitrator had dismissed the claim, finding it had little merit and was not supported by credible medical evidence.

The Director's Delegate dismissed the appeal, finding no error in the arbitrator's exercise of discretion to deny expenses.

The applicant was injured in a motor vehicle accident and received income replacement benefits until the insurer terminated them at the 104-week mark.

The applicant brought a motion for interim benefits and a special award, arguing the insurer failed to follow the termination provisions of the Statutory Accident Benefits Schedule.

The arbitrator found that the insurer unreasonably withheld benefits by failing to properly transition the applicant to loss of earning capacity benefits or continue the termination procedure.

The arbitrator ordered the insurer to pay interim income replacement benefits, ongoing loss of earning capacity benefits, and a 10 percent special award for unreasonable delay.

The applicant was injured in a motor vehicle accident in January 1993 but did not notify the insurer or apply for statutory accident benefits until September 1994, almost 20 months later.

The insurer denied the claim due to the delay.

On a preliminary issue hearing, the arbitrator found that the applicant, who was a licensed insurance broker, did not have a reasonable excuse for the delay.

The applicant's assertion that she did not know the full extent of her injuries was rejected, as she had sought medical treatment shortly after the accident and was referred to a specialist within 13 months.

The arbitration was dismissed.

The applicant was injured in a motor vehicle accident while enrolled in a job-orientation program with a prospective employer.

At the time of the accident, he was earning a training wage but had a contract to begin work as a casual driver at a higher wage upon completion of the program.

The insurer paid income replacement benefits based on the training wage.

The arbitrator held that under section 4.3 of the Statutory Accident Benefits Schedule, the applicant was entitled to benefits based on the higher wage of the prospective casual driver position, as he had a legitimate contract of employment made before the accident to start that work within one year.

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

The insurer terminated benefits under the post-156 week test, which requires the insured to be continuously prevented from engaging in any suitable occupation or employment.

The arbitrator upheld the termination, finding the appellant failed to prove he was unable to perform other less strenuous work suited to his background, and that there was insufficient evidence linking his depression to the accident.

On appeal, the Director's Delegate confirmed the arbitrator's decision, concluding that the appellant did not meet the burden of establishing disability within the meaning of the Schedule.

The applicant claimed statutory accident benefits from the insurer, alleging she was injured as a passenger in a motor vehicle accident.

The insurer denied the claim on the basis that she was not a passenger in the vehicle at the time of the collision.

Following a hearing on this preliminary issue, the arbitrator found significant inconsistencies and contradictions in the evidence provided by the applicant and the driver, particularly when compared to the investigating police officer's notes.

The arbitrator concluded that the applicant was not in the vehicle at the time of the accident and dismissed her claim for benefits.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits, including income replacement benefits, supplementary medical benefits, and attendant care benefits.

The insurer terminated income replacement benefits, alleging the applicant failed to attend a medical examination and was malingering.

The arbitrator found that the insurer improperly terminated benefits before obtaining a Designated Assessment Centre report, entitling the applicant to benefits until the report's release.

However, the arbitrator concluded the applicant grossly exaggerated his physical and cognitive symptoms, relying on surveillance evidence and medical inconsistencies, and denied ongoing income replacement benefits.

The arbitrator also awarded limited supplementary medical and attendant care benefits, and a special award due to the insurer's unreasonable delay in initial payments and refusal to fund certain treatments.