OFSCDRS 1999

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

The insurer denied benefits and argued that the applicant was precluded from proceeding to mediation and arbitration because she filed her application late, failed to provide requested medical information, and failed to attend medical examinations and assessments.

The arbitrator found that the applicant had a reasonable excuse for the late application, as her doctor failed to complete it promptly.

The arbitrator also found that the applicant had provided the necessary authorizations for medical records and was not responsible for third-party delays in producing them.

Furthermore, the applicant did not fail to make herself reasonably available for examinations, as the insurer failed to provide reasonable notice.

The insurer's preliminary objections were dismissed, and the applicant was permitted to proceed to arbitration.

The applicant was injured in a motor vehicle accident and received income replacement benefits (IRBs) until the insurer terminated them based on a DAC assessment.

The applicant sought ongoing IRBs, supplementary medical and housekeeping expenses, and the cost of a medical report.

The insurer sought repayment of an overpaid benefit.

The arbitrator found the applicant was not a credible witness due to inconsistent pain behaviour, discrepancies between his testimony and medical records, and surveillance video showing him working.

The arbitrator concluded the applicant did not suffer a substantial inability to perform his essential tasks as an auto mechanic and dismissed the claims for ongoing IRBs, physiotherapy, and housekeeping expenses.

The claim for the medical report cost was also dismissed as it was obtained for litigation.

The insurer's claim for repayment was dismissed for failing to provide the required notice.

The applicant, a taxi driver, was injured in a motor vehicle accident and received weekly income benefits for approximately one year.

He disputed the insurer's termination of benefits, claiming a substantial inability to perform the essential tasks of his occupation due to reduced working hours, and later claiming he was continuously prevented from engaging in any suitable occupation.

The arbitrator found the applicant's self-reported post-accident income records lacked credibility, particularly when contradicted by surveillance evidence showing he worked longer hours and took more fares than recorded.

The arbitrator concluded the applicant was capable of working 12-hour shifts and did not suffer a substantial inability, except for a brief period following sinus surgery.

The claim for ongoing benefits was dismissed as the temporary disability did not meet the continuity requirement.

The appellant was injured in a snowmobile accident while receiving temporary total disability benefits from the Workers' Compensation Board for a prior workplace injury.

He appealed an arbitrator's decision calculating his weekly income benefits under the Statutory Accident Benefits Schedule by averaging his employment income over the full 52 weeks preceding the accident, without including his WCB benefits as income from employment.

The Director's Delegate dismissed the appeal, confirming that the statutory language requires averaging over the full 52 weeks and that WCB benefits do not constitute income from employment under the applicable Schedule.

The claim for a special award was also dismissed.

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

The applicant failed to appear at the arbitration hearing.

The arbitrator proceeded in the applicant's absence under the Statutory Powers Procedure Act.

Based on the insurer's evidence, which included surveillance and inconsistencies regarding the applicant's alleged employment, the arbitrator dismissed the claims for income replacement, medical, and housekeeping benefits.

The applicant was ordered to pay $3,000 in expenses to the insurer for prolonging and obstructing the proceeding.

The applicant was injured in a motor vehicle accident and received income replacement benefits until the insurer terminated them, arguing she was no longer disabled.

The applicant sought further income replacement benefits and payment for medical and rehabilitation expenses.

The arbitrator found that the applicant was not substantially unable to perform the essential tasks of her pre-accident employment, noting her refusal to attempt a return to work and relying on the opinions of her treating physician and psychologist.

The claim for income replacement benefits was dismissed.

However, the arbitrator allowed the claim for medical and rehabilitation expenses, finding the treatments reasonable and beneficial.

The applicant was struck by a vehicle while crossing the street and claimed statutory accident benefits for income replacement, housekeeping, and travel expenses.

The insurer denied income replacement benefits after December 26, 1995, and housekeeping expenses.

At arbitration, the arbitrator found the applicant to be an unreliable historian whose testimony was contradicted by video surveillance showing him walking normally.

The medical evidence did not support the applicant's claims of debilitating physical or cognitive impairments preventing him from performing his job as a furniture assembler.

The claims for income replacement and housekeeping were dismissed, but the applicant was awarded $590 for uncontested travel expenses.

The applicant sought an assessment of legal and agent's fees following the settlement of a dispute over statutory accident benefits.

The insurer disputed the amount of time claimed by the applicant's legal assistants and lawyer.

The arbitrator adopted a global approach to assessing the fees, finding that the time claimed was excessive for the single issue involved.

The insurer was ordered to pay $1,819 in fees and GST.

The insured was injured in a motor vehicle accident while driving a rented van.

He initially applied for accident benefits from the van's insurer, which denied the claim.

He then applied to his wife's insurer, State Farm, which also denied the claim.

State Farm brought a preliminary issue motion to dismiss the arbitration as an abuse of process and a multiplicity of proceedings, arguing the insured was obligated to pursue the first insurer.

The arbitrator dismissed the motion, finding no legal basis to bar the insured from applying to State Farm, and noting that any priority dispute should be resolved between the insurers under O. Reg. 283/95.

The insured was awarded his expenses for the preliminary hearing.

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

The insurer terminated weekly income benefits.

The applicant commenced a civil action regarding medical and rehabilitation benefits, including a modified van.

The applicant later applied for arbitration regarding weekly income benefits and insurance for the van.

The insurer argued the arbitration was an abuse of process due to the concurrent civil action and sought repayment of its $3,000 assessment fee.

The arbitrator held that the applicant could proceed with the arbitration for weekly income benefits, as the issues were substantially different from the civil action.

However, the issue of insurance for the van was already part of the civil action and could not be arbitrated.

The applicant was not required to pay the assessment fee.

The applicant was injured in a motor vehicle accident and received income replacement benefits for 104 weeks.

The insurer then offered a loss of earning capacity benefit of zero and ceased paying income replacement benefits.

The applicant requested a Residual Earning Capacity Assessment at a Designated Assessment Centre (REC DAC) and sought reinstatement of her income replacement benefits pending the report.

The REC DAC report failed to determine a residual earning capacity.

The arbitrator held that under section 23 of the Statutory Accident Benefits Schedule, the insurer is not authorized to substitute a loss of earning capacity benefit until the release of a valid REC DAC report.

The insurer was ordered to pay ongoing income replacement benefits from the date of termination, subject to review by the hearing arbitrator.

Zurich Insurance Company appealed an arbitration order granting the respondent ongoing weekly income benefits, housekeeping expenses, and a special award.

The Director's Delegate found that the arbitrator erred in her interpretation of the post-156 week test under s. 13(8)(b) of the Statutory Accident Benefits Schedule by improperly categorizing the respondent's pre-accident activities and misinterpreting 'substantially all' to mean 'most'.

The Delegate also rescinded the special award, finding that Zurich had an acceptable basis for terminating the benefits.

The appeal was allowed, and a new arbitration hearing was ordered.

The applicant was injured in a minor motor vehicle accident and claimed medical and rehabilitation benefits for various assistive devices, including a boat, snowmobile, and ATV, to help him function at his remote cottage.

The insurer denied the claims, arguing the need for the devices arose from a pre-existing back condition.

The arbitrator found that the applicant had a long history of severe back problems, including a prior surgery, and that the minor car accident did not materially contribute to his need for the assistive devices.

The claim for benefits was dismissed.

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

The insurer calculated his gross annual income from employment without including the benefit premiums paid by his employer.

The arbitrator held that employer-paid benefit premiums are included in 'gross annual income from employment' under the Statutory Accident Benefits Schedule, as they are a form of compensation and 'income' should be interpreted broadly.

The insurer was ordered to pay the benefits owing with interest.

The applicant was injured in a motor vehicle accident and claimed income replacement benefits, alleging he was employed as a mechanic.

The arbitrator found that while the applicant was employed at the time of the accident, he failed to provide reliable evidence to substantiate the amount of his income, as the employment documents were created after the fact and contained inconsistencies.

Consequently, the applicant did not establish the amount of his income replacement benefits.

The insurer was granted an interim order for repayment of $3,239.34 for benefits previously paid in excess of the minimum rate, due to the applicant's wilful misrepresentation of his income.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits, including medical/rehabilitation benefits and income replacement benefits.

The insurer terminated treatment payments and income replacement benefits based on medical assessments.

At arbitration, the tribunal ordered the insurer to pay for physiotherapy treatment up to the date the applicant received the Designated Assessment Centre (DAC) reports, at the rates charged by the clinic.

However, the tribunal dismissed the claim for ongoing income replacement benefits, finding that the medical evidence, including psychiatric and orthopaedic assessments, did not establish a substantial inability to perform the essential tasks of her pre-accident employment as a sewing machine operator.

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

Following a preliminary decision that barred her claim for other disability benefits due to a missed limitation period, the insurer requested that the remainder of the arbitration be dismissed.

The arbitrator found that the applicant had not provided details or documentation for any other outstanding claims, nor had they been properly mediated.

Consequently, the application for arbitration was dismissed as there were no remaining issues in dispute.

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

The insurer argued the applicant was not substantially disabled and had misrepresented his pre-accident income and post-accident earnings.

The arbitrator found the applicant's evidence regarding his symptoms and finances to be highly unreliable, noting deliberate misrepresentations.

However, objective medical evidence of a large disc herniation, materially related to the accident, established that he was physically incapable of returning to the essential duties of his pre-accident employment.

The arbitrator ordered ongoing income replacement benefits and granted a $10,000 special award because the insurer had unreasonably reduced benefits earlier in the claim based solely on the applicant's receipt of unemployment insurance.

The applicant, a child care provider, was injured in a rear-end motor vehicle accident and claimed statutory accident benefits.

The insurer terminated her weekly income replacement benefits on multiple occasions.

The arbitrator found the applicant credible and accepted medical evidence that she developed chronic pain syndrome as a result of the accident, rendering her substantially disabled from performing the essential tasks of her employment.

The arbitrator ordered the insurer to pay income replacement benefits for the disputed periods and ongoing.

Additionally, the arbitrator found the insurer acted unreasonably in prematurely terminating benefits and awarded a special award of $3,500, along with interest and arbitration expenses.

The applicant, a 70-year-old pedestrian, was struck by a truck and sustained soft tissue injuries to her left shoulder and back.

The insurer terminated her statutory accident benefits in February 1997.

The applicant sought ongoing other disability benefits and rehabilitation benefits for case management services.

The arbitrator found that the applicant suffered a partial inability to carry on a normal life until March 1998, at which point her condition had stabilized such that she could perform most of her ordinary household tasks.

The arbitrator dismissed the claim for case management services, finding that the applicant's situation was not sufficiently complex to warrant a case manager given the support she already received from family, friends, and medical professionals.