OFSCDRS 1999

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

The applicant applied for arbitration, seeking weekly income benefits for the period from August 1994 to August 1996.

Although the arbitrator found the applicant to be a poor witness whose statements to medical assessors were unreliable, the arbitrator accepted the testimony of a lay witness who observed the applicant's physical limitations during a home renovation project.

The arbitrator concluded that the applicant suffered a substantial inability to perform the essential tasks of his pre-accident factory job due to back and leg pain caused by the accident.

The applicant was awarded weekly income benefits for the disputed period, plus interest.

The applicant sought statutory accident benefits, alleging she was injured when a public transit bus she was riding collided with another vehicle.

The insurer denied the claim on the basis that it had no record of the accident.

At the arbitration hearing, the applicant testified about the collision, but her evidence contained inconsistencies regarding the date, location, and route.

The insurer presented evidence from several employees detailing the transit authority's comprehensive accident reporting and vehicle tracking systems.

The tracking data demonstrated that the specific bus the applicant identified was across the city at the time, and no buses travelled the alleged route during the relevant timeframe.

The arbitrator concluded the applicant failed to prove on a balance of probabilities that the accident occurred and dismissed the claim.

The Applicants sought their arbitration expenses and a determination of the date from which interest should be calculated on shortfall payments of income replacement benefits following a previous arbitration decision.

The Arbitrator awarded the Applicants their arbitration expenses, finding that their claims were not frivolous or vexatious and they did not unreasonably prolong the proceedings.

Regarding interest, the Arbitrator determined that the payments became overdue on June 14, 1997, 30 days after the insurer received an accountant's report calculating the correct benefit amount, as it was impossible for the insurer to determine the correct amount prior to that date due to the Applicant's delay in providing financial information.

The applicant was injured in a minor rear-end motor vehicle accident and received income replacement benefits until they were terminated following a DAC assessment.

He applied for arbitration seeking reinstatement of IRBs, a loss of earning capacity benefit offer, and transportation expenses, claiming severe psychological and physical impairments.

The arbitrator dismissed the claims, finding that the applicant exaggerated his symptoms and was malingering.

The arbitrator concluded that the applicant's physical complaints were related to pre-existing conditions, including post-polio syndrome and degenerative disc disease, and that the minor impact of the collision could not account for his extreme clinical presentation.

Video surveillance showing the applicant walking normally without a cane further undermined his credibility.

The applicant was injured in a motor vehicle accident and sought ongoing income replacement benefits and medical benefits.

The insurer terminated benefits, arguing the applicant's ongoing disability was caused by severe pre-existing psychological and physical conditions, not the accident.

The arbitrator found that while the accident caused moderate soft tissue injuries, it did not significantly contribute to the applicant's disability beyond the termination date.

Claims for ongoing income replacement and most medical benefits were dismissed.

However, the arbitrator awarded a $5,000 special award against the insurer for unreasonable delays in paying benefits and adjusting the claim following clarifications in the law.

The applicant sought statutory accident benefits following a motor vehicle accident.

The insurer denied the claim, alleging the accident was staged and the applicant's employment was fabricated.

At the arbitration hearing, the insurer's key witness recanted his previous statements implicating the applicant.

Before the decision was issued, the insurer brought a motion to re-open the hearing under section 39 of the Dispute Resolution Practice Code to introduce new evidence from another witness.

The arbitrator dismissed the motion, finding that the insurer failed to exercise due diligence in discovering the evidence prior to the hearing and that the proposed hearsay evidence lacked sufficient credibility to affect the outcome.

The insurer was ordered to pay the applicant's expenses for the motion.

Following the dismissal of the applicant's arbitration for statutory accident benefits, the insurer sought an assessment of its expenses.

The arbitrator awarded the insurer legal fees for 36 hours of preparation and attendance, along with reasonable disbursements.

The insurer's claim for a $3,000 assessment fee under subsection 282(11.2) of the Insurance Act was denied because it was not raised during the arbitration hearing.

The insurer was also denied the costs of the expense assessment itself, as the applicant successfully disputed the assessment fee claim.

The appellant appealed an arbitrator's order dismissing her application for arbitration as premature and ordering her to pay a $3,000 assessment for abuse of process.

The Director's Delegate dismissed the appeal, finding that the issues in dispute had not been mediated as required by section 281(2) of the Insurance Act.

The appellant and her counsel had been given multiple opportunities to remedy the situation but failed to do so.

The arbitrator's finding of abuse of process and the resulting assessment were amply supported by the record.

The arbitrator issued a correction to a previous arbitration decision to include a ruling on the applicant's entitlement to reimbursement for medical reports.

The corrected decision confirms the applicant's entitlement to caregiver benefits, $52.35 for housekeeping expenses, and an $8,000 special award under the Insurance Act.

It adds an award of $1,110 for medical reports, plus interest.

The claim for psychological counselling was denied pending a current assessment.

The applicant was injured in a motor vehicle accident and sought payment for chiropractic and rehabilitation expenses incurred after the insurer terminated benefits based on a Designated Assessment Centre report.

The arbitrator found that the applicant was motivated to exercise on her own and did not require the supervised rehabilitation program, which was billed at an excessive hourly rate.

Furthermore, the arbitrator found no persuasive evidence that the continued chiropractic treatment was reasonable or necessary, noting that the treating chiropractor had not discussed the need for further treatment with the applicant.

The application for arbitration was dismissed.

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

The insurer terminated the benefits, and the applicant sought to elect to receive income replacement benefits instead.

The insurer argued that the applicant was deemed to have elected caregiver benefits under section 61(5) of the Statutory Accident Benefits Schedule because she failed to make an election within 30 days of receiving notice.

The arbitrator found that the insurer's letter did not constitute proper notice under section 61(2) because it did not advise the applicant of the requirement to choose between benefits or the consequences of failing to do so.

Therefore, the deemed election provision was not triggered, and the applicant was entitled to elect income replacement benefits.

The appellant was injured in a motor vehicle accident and claimed income replacement benefits (IRBs) and other expenses, arguing she was unable to continue her employment as a live-in housekeeper.

The arbitrator awarded IRBs for a brief period following the accident but concluded the appellant failed to prove ongoing disability, relying on surveillance evidence and testimony that she stopped working for reasons unrelated to the accident.

On appeal, the Director's Delegate upheld the arbitrator's decision, finding no error in the evaluation of medical evidence, the admission of hearsay, or the reliance on surveillance videotapes.

The appeal was dismissed, and the arbitrator's reduction of the appellant's expenses due to delay was affirmed.

The appellant appealed an arbitration order that dismissed his claims for income replacement benefits and ordered him to repay benefits previously received due to misrepresentation.

The arbitrator found that the appellant had lied about his pre-accident employment and medical history.

The Director's Delegate dismissed the appeal, finding no error in the arbitrator's assessment of the evidence and concluding that the appeal lacked merit.

The appellant was injured in a motor vehicle accident and sought payment for physiotherapy expenses from a private clinic.

The parties signed a settlement agreement releasing claims but requiring the insurer to pay expenses up to a certain date.

The insurer refused to pay the clinic's bill, arguing the treatment was reasonably available through OHIP.

The arbitrator dismissed the claim, finding she lacked jurisdiction to enforce the settlement.

On appeal, the Director's Delegate held that the arbitrator had jurisdiction to determine whether the settlement governed the benefits claimed and ordered the insurer to pay the clinic's fee pursuant to the settlement agreement.

The insurer appealed an arbitration order requiring it to pay ongoing income replacement benefits and a special award to the respondent, a self-employed home daycare provider injured in a motor vehicle accident.

The insurer argued the arbitrator erred in assessing the physical demands of the respondent's job and in rejecting the evidence of the Designated Assessment Centre (DAC) assessors, who concluded she could return to work.

The Director's Delegate dismissed the appeal, finding no error of law in the arbitrator's preference for the respondent's medical evidence over the DAC assessment, nor in the finding that the insurer acted unreasonably in terminating benefits on multiple occasions.

The applicant was injured in a motor vehicle accident while riding her bicycle and sought statutory accident benefits.

The insurer terminated her income replacement and medical/rehabilitation benefits based on designated assessment centre (DAC) reports.

The arbitrator found that the applicant suffered a substantial inability to perform the essential tasks of her employment as a house cleaner due to chronic pain, entitling her to income replacement benefits up to the two-year anniversary of the accident.

The arbitrator also awarded medical benefits for prescription medications and transportation expenses, but denied claims for chiropractic care and injections as they were not reasonable or necessary.

The claim for hydrotherapy was deemed premature.

The arbitrator declined to make a special award, finding the insurer's reliance on the DAC reports was not unreasonable.

The applicant was injured in a motor vehicle accident while working as a taxi driver.

He applied for income replacement benefits, and a preliminary issue hearing was held to determine whether he was 'employed' or 'self-employed' under the Statutory Accident Benefits Schedule.

The insurer argued he was an independent contractor, noting he paid a daily lease for the cab and received no T4.

The arbitrator applied common law tests for employment, finding that the taxi company controlled his hours, owned the vehicle and dispatch system, and bore the primary risk of profit and loss.

The arbitrator concluded the applicant was 'employed' and entitled to base his benefits calculation on the four weeks prior to the accident.

The applicant was injured in a motor vehicle accident and settled her claim for statutory accident benefits with the insurer prior to an arbitration hearing.

The parties agreed to have the applicant's expenses assessed by the Financial Services Commission of Ontario (FSCO).

The arbitrator held that FSCO has jurisdiction to award expenses even when the substantive issues are settled prior to a hearing, as the matter remains an 'arbitration proceeding' under the Insurance Act from the time the application is filed.

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

The parties attended mediation and executed a Release and Indemnity Agreement.

The insurer argued the agreement precluded the applicant from proceeding to arbitration for certain medical and rehabilitation benefits.

The arbitrator found the agreement ambiguous and admitted extrinsic evidence under an exception to the parol evidence rule.

The arbitrator concluded the parties intended to exclude the disputed clinic accounts from the release, allowing the applicant to proceed to arbitration.

The arbitrator issued a correction to a previous arbitration decision regarding a death benefit.

The original decision incorrectly awarded $10,250.46 under subsection 51(5) of the Statutory Accident Benefits Schedule.

The arbitrator corrected the amount to $10,000, which was the proper amount payable under Ontario Regulation 776/93 for an accident that occurred in 1994.