OFSCDRS 2000

The applicant was injured in a rear-end motor vehicle accident and received statutory accident benefits from the insurer.

The insurer terminated his medical rehabilitation benefits based on a Designated Assessment Centre report and the discharge report of his own chiropractor.

The applicant sought payment for ongoing chiropractic treatments, a special award, and arbitration expenses.

The arbitrator dismissed the claim for medical expenses, finding the applicant failed to provide objective medical evidence that the ongoing treatment was reasonable and necessary.

The claim for a special award was also dismissed as the insurer's denial was not unreasonable.

However, the arbitrator awarded the applicant his arbitration expenses, concluding that his claim was legitimate, presented in a timely manner, and not frivolous.

The applicant, a military reservist, was struck by a motor vehicle and received weekly income benefits for 198 weeks.

The insurer terminated benefits, arguing the applicant could return to light sedentary work.

The arbitrator found that while the applicant was physically capable of light sedentary work, he was not 'reasonably suited' for such employment by his education, training, or experience, given his long career in a demanding military role.

The arbitrator also determined the correct quantum of the weekly benefit based on bank records, as official payroll records were unreliable.

The insurer's claim for repayment of prior overpaid benefits was dismissed because the applicant did not contribute to the error.

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

The applicant sought ongoing benefits under subsection 12(5)(b) of the Statutory Accident Benefits Schedule, arguing she was continuously prevented from engaging in suitable employment.

The arbitrator found that the applicant lacked the physical capacity to return to her former physically demanding jobs and lacked the skills for sedentary office work without further retraining.

The arbitrator ordered ongoing weekly income benefits.

Additionally, the arbitrator awarded a $10,000 special award under section 282(10) of the Insurance Act because the insurer unreasonably terminated benefits without proper notice or justification.

The applicant was injured in a motor vehicle accident and sought weekly disability benefits and reimbursement for damaged clothing under the Statutory Accident Benefits Schedule.

The arbitrator found that the applicant's pre-existing heart condition and limited pre-accident activities meant she did not suffer a complete inability to lead a normal life as a result of the accident.

The claim for weekly disability benefits was dismissed.

The arbitrator awarded $175 for damaged clothing, finding insufficient evidence to support the $4,170 claimed for wholesale replacement.

The applicants claimed statutory accident benefits following an alleged motor vehicle accident.

They failed to comply with production orders, failed to attend medical examinations, and did not appear at the arbitration hearing.

Their counsel was granted leave to withdraw.

The arbitrator dismissed the claims for lack of evidence and found the arbitration to be an abuse of process, noting significant inconsistencies in the evidence regarding the alleged accident.

The insurer was awarded its expenses of the arbitration and a $3,000 assessment fee.

Both parties appealed an arbitration order concerning the calculation of Income Replacement Benefits (IRBs) and Loss of Earning Capacity Benefits (LECBs) following a motorcycle accident.

The insured challenged the arbitrator's treatment of vacation pay and the refusal to order a special award for delayed payments.

The insurer challenged the finding that the insured's residual earning capacity was zero due to a lack of available part-time employment in his community.

The Director's Delegate allowed the insured's appeal in part, recalculating the gross annual income using the 'income when received' approach for vacation pay, but dismissed the claim for a special award.

The insurer's appeal regarding residual earning capacity was dismissed, affirming that part-time employment availability must be specifically established.

The insurer appealed an arbitrator's decision that an excluded driver endorsement was valid but only took effect after the first of two motor vehicle accidents.

The insureds cross-appealed, arguing the endorsement was entirely invalid.

The Director's Delegate allowed the cross-appeal, finding that the endorsement was not validly executed because the insured and the excluded driver signed in the wrong places, and the insured, who faced a language barrier, did not have the requisite intent to exclude her husband.

The insurer's appeal was dismissed.

AXA Insurance Company appealed an arbitration order awarding Mario Rocca income replacement benefits beyond the 104-week mark and a $10,000 special award.

Rocca cross-appealed the calculation of his benefits regarding commission income.

The Director's Delegate found that despite the arbitrator's adverse credibility findings against Rocca, there was sufficient objective medical evidence, including an MRI showing a large disc herniation, to support the conclusion that he was disabled from the physical aspects of his pre-accident job.

The Director's Delegate also upheld the special award, finding the insurer unreasonably reduced benefits to the minimum level without an objective basis.

Both the appeal and cross-appeal were dismissed.

The insured was involved in two separate motor vehicle accidents and commenced multiple court actions against different insurers and tortfeasors.

She subsequently applied for arbitration at the Financial Services Commission of Ontario to claim specific chiropractic and dental expenses from her first insurer, Royal & SunAlliance.

The insurer appealed an arbitrator's preliminary order that allowed the arbitration to proceed and awarded interim benefits.

The Director's Delegate allowed the appeal, finding that the arbitration and court proceedings involved overlapping factual and legal issues, particularly regarding causation.

The arbitration was stayed pending the outcome of the court action to avoid duplicitous proceedings and inconsistent results.

The insured person was injured in a motor vehicle accident and commenced both a court action and an arbitration proceeding for statutory accident benefits.

The insurer appealed an arbitration order that allowed the arbitration to proceed despite the concurrent court action.

The Director's Delegate allowed the appeal, finding that the arbitrator erred by focusing only on whether the specific benefits claimed were different, rather than considering the substantial factual overlap between the two proceedings.

Applying the criteria for avoiding multiple proceedings, the Director's Delegate stayed the arbitration pending the outcome of the court action, noting that the court action was broader in scope and involved overlapping medical evidence and causation issues.

The applicant was seriously injured in a motor vehicle accident in India in 1994 that killed three family members.

He applied for statutory accident benefits in 1998, approximately three and a half years after the 30-day time limit.

The insurer refused to pay benefits due to the delay.

The arbitrator found that the applicant had a reasonable excuse for the delay under subsection 59(4) of the Schedule, as his father had reasonably relied on incorrect advice from an insurance agent that coverage did not extend to overseas accidents, and acted expeditiously once he received correct legal advice.

The applicant sought payment for various medical and functional assessments following a motor vehicle accident.

At the hearing, the insurer requested the arbitration be dismissed due to the applicant's failure to comply with pre-hearing production orders.

The arbitrator found the applicant's refusal to produce documents constituted an abuse of process, warranting a stay.

However, proceeding to the merits, the arbitrator concluded the assessment expenses were not reasonable under section 24 of the Statutory Accident Benefits Schedule, as they were unnecessary and duplicative of prior assessments.

The application for arbitration was dismissed.

The applicant was injured when struck by a vehicle and sought payment from his insurer for a multidisciplinary assessment conducted by DEAHY Medical Assessments Inc., totalling $2,461.

The insurer denied the benefit, arguing the assessments were unnecessary, duplicative, and unreasonably priced.

The arbitrator found that the physiotherapy and functional capacity assessments were reasonable and payable, but the orthopaedic assessment was unnecessary as the applicant should have sought a report from his treating surgeon.

The arbitrator ordered the insurer to pay $1,498 plus interest, and dismissed the applicant's claim for a special award.

The applicant sought her expenses for an arbitration proceeding regarding statutory accident benefits following a motor vehicle accident.

Although she was awarded only $1,050 on a claim of over $17,000, the arbitrator found she was successful because she had to pursue arbitration to recover her entitlement.

The insurer's settlement offer of $2,500 was given little weight because it required a full release of future medical and rehabilitation claims.

The arbitrator concluded the applicant was entitled to her expenses of the arbitration proceeding.

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

The insurer raised a preliminary issue that the applicant failed to file for arbitration within the two-year limitation period under s. 281(5) of the Insurance Act.

The arbitrator reviewed the correspondence and notices provided by the insurer to determine if they constituted clear and unequivocal denials.

The arbitrator found that the claims for further disability benefits, taxi expenses, prescriptions, cognitive aids, biobeam, and certain rehabilitation expenses were statute-barred.

However, the claims for vocational rehabilitation and case management services were not clearly denied and may proceed to arbitration.

The applicant was injured in a motorcycle accident and received weekly income benefits until the insurer terminated them in December 1996.

The applicant sought ongoing benefits under the post-104 week test, arguing he was continuously prevented from engaging in any suitable occupation.

Following the accident, the applicant started a small business selling garlic spread.

The arbitrator found that while the applicant could not return to his pre-accident employment, he had developed transferable skills through his new business that made sedentary sales work a suitable occupation.

However, because these skills were only developed after running the business for some time, the arbitrator awarded an additional 52 weeks of benefits, concluding the applicant was capable of working full-time by December 1997.

The claim for a special award was dismissed.

The insurer appealed an arbitrator's decision awarding the insured a loss of earning capacity benefit of $459.58 per week and sought a stay of the order pending the appeal.

The Director's Delegate applied the three-part test for a stay, focusing heavily on the hardship to the parties.

Finding that withholding ongoing benefits would cause significant hardship to the impecunious insured, the Delegate refused to stay the ongoing payments.

However, given the large accumulation of arrears (approximately $82,000) and the risk of non-recovery if the appeal succeeded, the Delegate granted a partial stay, staying the arrears accumulated between October 1996 and December 1999, while ordering the payment of arrears from January 2000 onwards.

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

During an arbitration hearing on entitlement to income replacement benefits, the hearing arbitrator adjourned the matter and purportedly severed the issue of quantum to be heard by a different arbitrator.

At the subsequent hearing on quantum, the new arbitrator raised the issue of jurisdiction.

The arbitrator held that the issue of quantum was a necessary sub-issue of entitlement and could not be severed without statutory authority.

As the original hearing arbitrator remained seised of the issue, the separate hearing on quantum was declared a nullity.

Following a decision denying the applicant statutory accident benefits due to an unexcused delay in notifying the insurer, the arbitrator considered the issue of expenses.

The arbitrator declined to award expenses to the applicant because he was unsuccessful and his evidence was unreliable.

The arbitrator also declined to award expenses to the insurer, noting that the applicant's position was not unreasonable, he had limited financial resources, and an award of expenses could deter meritorious claims.

Both parties were ordered to bear their own expenses.

The insurer appealed an arbitration order finding that the insured, a taxi driver, was an employee rather than self-employed at the time of his motor vehicle accident.

The insured paid a flat daily lease rate for his taxi, kept all fares and tips, and reported his earnings as business income.

The Director's Delegate allowed the appeal, holding that the insured was self-employed.

The Delegate found that the arbitrator erred by redefining the employment relationship simply to allow the insured to use the more favourable four-week pre-accident income calculation period available to employees under the Statutory Accident Benefits Schedule.