OFSCDRS 2000

Following a preliminary issues hearing where the applicant was ordered to pay the insurer's expenses, the insurer sought $1,059.11 in costs.

The arbitrator found the preparation time claimed by the insurer to be somewhat excessive, reducing it from 9.1 hours to 5.1 hours.

The applicant was ordered to pay the insurer $757.59 in expenses for the preliminary issues hearing.

The applicant was struck by a slow-moving vehicle while walking in a parking lot and claimed ongoing income replacement benefits for chronic pain.

The insurer terminated benefits based on an independent medical examination finding no objective injury.

At arbitration, the arbitrator found the applicant's subjective complaints of disabling pain were not credible, noting inconsistencies in her testimony regarding child care, her refusal of recommended treatments, and surveillance video showing her walking briskly and moving freely.

The arbitrator concluded the applicant failed to prove she was substantially disabled from performing the essential tasks of her employment and dismissed the claim.

The applicant was injured in a motor vehicle accident and subsequently signed a full and final release settling her claims for statutory accident benefits for $16,750.

She later sought to proceed with arbitration, arguing the settlement was unenforceable due to a clerical error regarding the accident date, inadequate disclosure of the commuted value of benefits under the Settlement Regulation, and mistaken assumptions.

The Arbitrator held that the clerical error was subject to rectification, the applicant failed to prove the settlement was improvident or based on a mistaken assumption, and the insurer's disclosure statement strictly complied with the Settlement Regulation by providing the commuted value based on maximum policy limits.

The request to proceed with arbitration was denied.

The applicant was injured in a motor vehicle accident and applied for arbitration claiming ongoing weekly income benefits.

The insurer requested an Insurer's Medical Examination (IME) shortly before the scheduled arbitration hearing, which the applicant refused to attend.

The insurer sought an adjournment of the hearing.

The arbitrator found the insurer's request for an IME unreasonable due to its proximity to the hearing date and the insurer's failure to request it earlier despite having ample opportunity.

The request for an adjournment was dismissed.

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

The arbitrator determined the appellant was self-employed and attributed 50% of his closely held family company's profits to him, with the remainder attributed to his wife and children who also worked in the business.

The appellant appealed, arguing that 100% of the profits should be attributed to him as the sole voting shareholder and key person.

The Director's Delegate dismissed the appeal, finding the arbitrator properly considered the share structure, expectation of profit, relative contributions, and degree of risk of all family members.

The appeal regarding the applicable claim code was also dismissed.

The applicant was injured in a motor vehicle accident and received income replacement benefits (IRBs) for over 104 weeks before the insurer terminated them.

The arbitrator found that the insurer failed to comply with its statutory duty to provide a loss of earning capacity (LEC) offer at the 104-week mark, and ordered the insurer to continue paying IRBs until it complied.

The arbitrator also found the applicant suffered a substantial inability to perform the essential tasks of her employment as a gas station cashier due to accident-related headaches and neck pain.

The applicant was awarded costs for massage therapy and a medi water pillow, but claims for a convertible vehicle, boat canvas top, chiropractic care, and a hard bite plate were dismissed.

A special award of $15,000 was granted against the insurer for unreasonably withholding IRBs.

The insurer brought a preliminary motion arguing that the applicant was barred from proceeding to arbitration because he failed to cooperate with a disability DAC assessment, contrary to s. 64(9) of the Statutory Accident Benefits Schedule.

The insurer alleged the applicant refused to sign a consent form or provide medical records.

The arbitrator preferred the applicant's evidence that he answered all questions and had previously signed authorizations for the insurer to obtain his medical records.

The arbitrator found the applicant complied with his obligations and dismissed the insurer's motion, allowing the arbitration to proceed.

The applicant was injured in three motor vehicle accidents.

She applied for statutory accident benefits.

The insurer relied on section 21(9) of the Schedule to delay making a loss of earning capacity benefit (LECB) offer until two years after the second accident.

A RECDAC assessment concluded she could work full-time as a parking lot attendant.

The arbitrator found the applicant to be an unreliable historian due to her failure to disclose a significant pre-accident history of workplace injuries.

However, based on the medical evidence, the arbitrator found she suffered significant psychological and physical impairments.

The arbitrator concluded the RECDAC overestimated her functional abilities, finding she could only work part-time as a parking lot attendant.

Claims for acupuncture and a special award for delay were dismissed.

The applicant was injured in a motor vehicle accident and received income replacement benefits until the insurer terminated them based on medical assessments indicating he could return to his pre-accident employment as a machine operator.

The arbitrator found that the insurer's assessments relied on a flawed ergonomic report that incorrectly classified the applicant's job as sedentary to light.

The arbitrator accepted the applicant's evidence that his job required significant standing, bending, and lifting, which he could no longer perform for a full shift due to ongoing knee pain and swelling.

The applicant was awarded ongoing income replacement benefits and supplementary medical benefits for physiotherapy, while the insurer's claims for repayment and a special award were dismissed.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for fitness classes, chiropractic and massage treatments, acupuncture, and housekeeping expenses.

The arbitrator found that the applicant suffered from chronic pain and reasonably required the fitness classes and ongoing chiropractic and massage treatments.

The claim for acupuncture was also allowed, as the applicant established a prima facie case for its reasonableness.

However, the claim for housekeeping and home maintenance expenses was dismissed because the evidence, including a functional capacity evaluation, showed the applicant was capable of performing the tasks by pacing herself.

Finally, the arbitrator ordered the insurer to pay a special award of $350 for unreasonably withholding chiropractic benefits pending dispute resolution.

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

After failing to comply with multiple production orders and failing to attend the arbitration hearing, the arbitrator proceeded in his absence.

The applicant's claim for income replacement benefits was dismissed for lack of evidence.

The insurer's claims for repayment of benefits and a special award for a frivolous proceeding were also dismissed.

However, the arbitrator ordered the applicant to pay the insurer's expenses of $2,216.89 because his conduct, including failing to obey production orders and not attending the hearing, unreasonably prolonged the proceedings.

The applicant claimed he was struck by a motor vehicle while crossing the street on July 15, 1998, and sought statutory accident benefits.

The insurer disputed the date and cause of the injuries, arguing the incident occurred on July 16 and did not cause the impairment.

In a preliminary issue hearing, the arbitrator found the applicant's version of events, supported by objective evidence from his workplace and hospital records, established on a balance of probabilities that he sustained an impairment as a result of the motor vehicle incident on July 15, 1998.

The applicant was permitted to proceed to a hearing on his entitlement to benefits.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits, including Loss of Earning Capacity Benefits (LECBs), speech therapy, and psychotherapy.

The insurer disputed the calculation of her pre-accident earning capacity, arguing she would not have worked full-time in the future due to a pre-existing back injury.

The arbitrator held that the applicant only needed to demonstrate a real or serious possibility of future full-time employment under section 86 of the Schedule, which she successfully established.

The arbitrator also ordered the insurer to pay for missed and ongoing speech and psychological therapies, finding that the expenses were 'incurred' even though the missed treatments could no longer be obtained, and that the insurer improperly relied on outdated Designated Assessment Centre (DAC) reports to terminate benefits.

The claim for a special award was dismissed.

The insurer brought a motion for an order requiring the insured to attend several independent medical examinations, including an endocrinologist, a work capacity and functional abilities evaluation, a vocational assessment, and a psychological evaluation.

The arbitrator granted the requests for the endocrinologist, the physical examination by a medical doctor, and the psychological evaluation, finding them reasonable given the passage of time since previous assessments and the recent medical reports served by the insured.

The requests for a functional abilities evaluation and a vocational assessment were denied as unreasonable and too close to the scheduled arbitration hearing.

The applicant sought interim payment of dental and chiropractic accounts under the 'pay pending dispute' provisions of the Statutory Accident Benefits Schedule following a 1993 motor vehicle accident.

The insurer moved to dismiss the arbitration as duplicitous with the applicant's civil action and sought to introduce defence medical reports obtained in that action.

The arbitrator admitted the medical reports, finding the interests of justice outweighed the deemed undertaking rule, but refused to dismiss the arbitration, holding the claims were distinct.

The arbitrator ordered the insurer to pay the medical accounts on an interim basis, finding the applicant had established the requisite de minimis connection between the accident and the treatment.

The applicant was injured in a motor vehicle accident and sought income replacement benefits, alleging he had a legitimate contract of employment to commence work as a truck driver shortly after the accident.

The insurer disputed the existence of the contract.

The arbitrator reviewed the evidence, including the financial viability of the alleged guaranteed weekly wage in a seasonal industry, and found the applicant's evidence improbable.

The arbitrator concluded the applicant failed to establish the existence of a legitimate contract of employment entered into prior to the accident, and dismissed the claim.

The insurer appealed an arbitrator's decision that it was not entitled to deduct CPP disability benefits from the insured's weekly income benefits and that the insured's application for arbitration was not time-barred.

The Director's Delegate dismissed the appeal, confirming that CPP disability benefits are not deductible from statutory accident benefits.

Furthermore, the Director's Delegate held that the insurer's adjustment of the benefit amount to reflect the CPP payments did not constitute a 'refusal to pay' the benefit claimed, and therefore the two-year limitation period under the Insurance Act had not been triggered.

The applicant was injured in a rear-end motor vehicle accident and sought statutory accident benefits, including non-earner, attendant care, and housekeeping benefits.

The arbitrator dismissed the claims for non-earner, attendant care, and housekeeping benefits, finding that the applicant did not suffer a complete inability to carry on a normal life, as evidenced by video surveillance and her own statements.

The arbitrator also found no evidence that the applicant incurred expenses for care provided by her daughter.

The applicant was awarded $15.53 for transportation expenses to medical appointments.

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

The insurer terminated benefits in October 1994, stating the applicant did not meet the post-156 week disability test.

The applicant did not dispute the termination at the time.

In 1998, the applicant claimed a relapse and sought benefits from September 1997 onwards.

The arbitrator held that the applicant was precluded from proceeding to arbitration because the two-year limitation period under the Insurance Act and the Statutory Accident Benefits Schedule had expired following the initial clear and unequivocal refusal in 1994.

The arbitrator rejected the argument that a relapse could trigger a new limitation period without continuity of disability.

The applicant was injured in a motor vehicle accident and sought various supplementary medical, rehabilitation, and housekeeping benefits after the insurer terminated weekly benefits.

The arbitrator found that the applicant had a significant pre-accident history of chronic pain and had largely recovered from the accident-related soft tissue injuries by December 1995.

Most of the claimed expenses, including physiotherapy, massage therapy, and trips to India, were denied for lack of evidence connecting them to the accident.

However, the arbitrator allowed expenses for a dental bite plane and related travel, finding they were reasonably incurred for a temporomandibular joint impairment caused by the accident.