OFSCDRS 1999

The applicant was injured in a motor vehicle accident and received weekly income replacement benefits until the insurer terminated them at the 156-week mark.

The insurer argued the applicant could return to work in a suitable occupation, such as a millwright foreman.

The arbitrator found that the applicant had developed a chronic pain syndrome as a result of the accident, which caused fluctuating symptoms, fatigue, and poor endurance.

Applying the post-156 week test, the arbitrator concluded that the applicant's condition continuously prevented him from engaging in any occupation or employment for which he was reasonably suited, including part-time sedentary work.

The insurer was ordered to pay ongoing weekly income replacement benefits and interest.

The applicant was injured in a motor vehicle accident and reported it to the insurer two days later.

The insurer mailed an application package, but the applicant did not submit it until over nine months after the 90-day time limit expired.

The applicant claimed he was unaware of the time limit because the explanation form was missing from his package.

The arbitrator rejected this argument, finding it implausible that the insurer removed the form and noting the applicant's lack of medical treatment or follow-up.

The arbitrator concluded the applicant failed to demonstrate a reasonable excuse for the delay, and the claim for accident benefits was dismissed.

The applicant was injured in a motor vehicle accident and claimed statutory accident benefits, including income replacement and housekeeping expenses, arguing she could no longer work as a live-in housekeeper.

The arbitrator found that while the applicant sustained genuine injuries, including vertigo and cervicogenic pain, she exaggerated her limitations and was only disabled from working until her employer returned from Florida on February 21, 1996.

Income replacement benefits were awarded up to that date, along with a 50% special award because the insurer unreasonably withheld payment despite having uncontradicted medical evidence of disability for that initial period.

Claims for ongoing income replacement, housekeeping, and a case manager were dismissed.

The insurer brought a motion for interim expenses against the applicant due to the conduct of the applicant's counsel.

The applicant's counsel failed to attend a scheduled pre-hearing discussion without a reasonable excuse and failed to comply with undertakings to produce medical authorizations and an OHIP summary within the required timelines.

The arbitrator found that the counsel's conduct prejudiced the insurer and frustrated the Commission's mandate to facilitate settlement.

The arbitrator ordered the applicant to pay $300 in interim expenses to the insurer, noting that the award should ideally be paid personally by the counsel.

The applicant sought statutory accident benefits, claiming he was an occupant of an insured vehicle involved in a collision.

The insurer denied benefits on the basis that the applicant was not an occupant of the vehicle at the time of the accident.

The arbitrator found the applicant's evidence to be inconsistent and unreliable, and preferred the evidence of the third-party driver and the insurer's accident reconstruction experts.

The arbitrator concluded that the applicant was not an occupant of the vehicle and therefore not an insured person entitled to benefits.

The application was dismissed, and the applicant was ordered to pay $3,000 to the insurer for commencing a frivolous and vexatious arbitration.

The applicant was injured in a motor vehicle accident and received weekly income benefits before returning to full-time work as a campus police officer.

She continued to miss occasional days of work due to ongoing symptoms and claimed income benefits for those days, as well as for a three-week period following a physiotherapy program.

The arbitrator found that while the applicant was substantially unable to perform the essential tasks of her employment on the occasional days missed, the deduction of 80 percent of her post-accident income under section 15 of the Schedule reduced the payable benefit to zero.

The arbitrator also found the applicant was not disabled during the three-week period in December 1997 and dismissed the claim for a special award, concluding the insurer had not acted unreasonably.

The applicant was injured in a motor vehicle accident and applied for statutory accident benefits, including caregiver benefits, housekeeping expenses, and the cost of an occupational therapy assessment.

The insurer denied the claims.

At arbitration, the arbitrator found that the applicant did not meet the "substantial inability" test for caregiver or housekeeping benefits, as she had returned to work and caregiving shortly after the accident with only minor residual complaints.

However, the arbitrator ordered the insurer to pay for the occupational therapy assessment, finding it was a reasonable expense and not subject to the conflict of interest disclosure provisions of section 38 of the Schedule.

The applicant's claim for a special award was dismissed.

The applicant failed to attend a scheduled preliminary hearing regarding his entitlement to caregiver benefits following a motor vehicle accident.

The insurer sought to have the application dismissed.

The arbitrator found that the applicant's failure to attend was excusable due to his undisputed psychiatric condition and lack of a fixed address, which likely resulted in him not receiving actual notice of the hearing.

The application was not dismissed, and the preliminary hearing was adjourned.

The issue of expenses was deferred to the hearing arbitrator.

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

The insurer terminated caregiver benefits and scheduled a medical examination.

The applicant attended but refused to proceed unless she could tape record the examination, alleging the doctor had been rude previously.

The doctor refused to proceed with the tape recorder.

On a preliminary motion, the arbitrator applied the principles from Bellamy v. Johnson and held that the applicant's refusal to submit to the examination without a tape recorder was unreasonable, as she failed to demonstrate a bona fide concern or propose safeguards to ensure the recording's reliability.

The applicant was injured while a passenger on a TTC streetcar.

She did not notify her husband's insurer of her intention to apply for accident benefits until 11 months after the accident, well past the 30-day requirement under section 59 of the Statutory Accident Benefits Schedule.

The insurer denied the claim due to late notice.

The applicant argued she had a reasonable excuse because her husband, fearing increased premiums, refused to provide his insurance details despite her repeated requests.

The arbitrator found that the applicant's excuse was reasonable given the family's patriarchal dynamic and her inability to obtain the information otherwise.

The insurer's motion to dismiss the claim was denied, allowing the applicant to proceed to arbitration on the merits.

The applicant was involved in two motor vehicle accidents and sought ongoing income replacement and supplementary medical benefits (chiropractic treatments) from the insurer.

The insurer terminated benefits, arguing the applicant was no longer disabled or that any disability was due to pre-existing conditions or the second accident.

The arbitrator found that the applicant's pre-existing back and shoulder injuries from prior workplace falls were the true cause of his inability to work as a carpenter, and the accidents did not significantly exacerbate his condition.

The claim for ongoing chiropractic expenses was also dismissed as the applicant failed to prove the treatments were reasonable or effective in light of a negative DAC assessment.

Following a successful arbitration regarding statutory accident benefits, the applicant sought arbitration expenses of $1,225.81.

The insurer argued that each party should bear its own expenses because the legal issue was uncertain.

The arbitrator rejected the insurer's argument, finding that the law was not uncertain and the insurer's position lacked novelty or complexity.

The arbitrator awarded the applicant his full claimed expenses of $1,225.81.

The applicant, a real estate agent, was injured in a motor vehicle accident and claimed income replacement benefits.

The insurer argued she was self-employed and sought to deduct her employment expenses from her gross commission income, and also claimed an overpayment.

The arbitrator found that the applicant was an employee of the real estate brokerage, not an independent contractor.

The arbitrator further held that under the Statutory Accident Benefits Schedule, employment expenses cannot be deducted from gross employment income when calculating benefits.

Finally, the arbitrator determined that real estate commissions should be recognized on the firm deal date rather than the closing date.

The applicant was awarded outstanding benefits with interest, and the insurer's claim for repayment was dismissed.

The applicants, who were injured in a motor vehicle accident, sought an interim award for the payment of physiotherapy expenses and a special award against the insurer for unreasonably withholding payment.

The insurer argued that the applicants had not provided a 'Certificate of Reasonableness' or established that they suffered an impairment as a result of the accident.

The arbitrator dismissed the motion, finding that the applicants failed to establish a prima facie case for entitlement to the benefits and did not demonstrate sufficient urgency to justify an interim order.

The request for a special award was also dismissed as inappropriate on an interim basis.

The arbitrator issued a decision correction to amend a typographical error in the arbitration order dated April 19, 1999.

The start date for a 24-week period was corrected from April 2, 1995, to April 26, 1996.

The applicant was injured in a motor vehicle accident and received weekly income benefits until the insurer terminated them on June 30, 1994.

The applicant applied for mediation in 1996 and subsequently for arbitration in November 1997.

The insurer raised a preliminary issue that the arbitration application was statute-barred under section 281(5) of the Insurance Act.

The arbitrator found that the two-year limitation period began running on June 30, 1994, and was extended for 90 days following the mediator's report on September 23, 1996.

As the application was filed nearly 11 months after the extended limitation period expired, the claim for weekly income benefits was statute-barred.

The appellant, Algoma Mutual Insurance Co., appealed a decision involving the respondent.

On consent of the parties, the Appeals Delegate ordered that the appeal be dismissed.

The parties agreed that the order is final and not subject to further appeal, variation, revocation, or judicial review.

The Applicant sought statutory accident benefits after fracturing his ankle while falling from a fence.

He claimed he was climbing the fence to access the backyard and open a carport door from the inside to assist his father in parking a car.

The Insurer denied the claim, arguing the incident did not meet the definition of an 'accident' under the Schedule.

The arbitrator found the Applicant's evidence regarding the existence of the carport door not credible.

Furthermore, even if the evidence were accepted, the connection between climbing a fence 500 feet away and the use or operation of an automobile was too remote.

The application was dismissed, and the Applicant was ordered to pay the Insurer's expenses.

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

Prior to a pre-hearing, her family doctor sent a letter stating she suffered from paranoid schizophrenia and was not mentally competent to make decisions regarding her file.

The arbitrator held a preliminary issue hearing to determine if she required a litigation guardian under the Dispute Resolution Practice Code and the Substitute Decisions Act.

The arbitrator found that the doctor's letter did not constitute compelling evidence to overturn the presumption of capacity.

Based on the applicant's testimony and demonstrated ability to manage her daily life and finances, the arbitrator concluded she was mentally capable of proceeding with her arbitration without a litigation guardian.

The Arbitrator issued a correction to a previous decision on a preliminary issue, changing the date 'March 27, 1995' to 'May 27, 1995' in two places.