OFSCDRS 2001

The applicant sought death and funeral benefits after her son was shot and killed in an underground parking garage while performing maintenance on his vehicle.

The insurer denied the claim on the basis that the death was not an 'accident' under the Statutory Accident Benefits Schedule.

The arbitrator dismissed the application, finding that the vehicle did not play a direct instrumental role in the chain of events leading to the death.

The direct and intervening cause of death was the gunshot, not the normal use and operation of the automobile.

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

Disputes arose regarding her entitlement to medical benefits for treatment at a rehabilitation clinic, housekeeping expenses, the cost of a psychological assessment, and a special award.

The arbitrator found that the applicant's right knee problems and chronic pain syndrome were materially contributed to by the accident, making the clinic's treatment reasonable and necessary.

The claim for housekeeping expenses was dismissed due to inconsistencies in the evidence.

The cost of the psychological assessment was awarded as it was reasonable for the applicant's counsel to request it.

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

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

The insurer denied the claim for treatment expenses.

The applicant applied for mediation and subsequently arbitration.

The insurer raised a preliminary issue that the application for arbitration was filed beyond the two-year limitation period under section 281(5) of the Insurance Act.

The arbitrator found that a letter from the applicant's paralegal representative constituted an admission of actual notice of the insurer's refusal to pay benefits.

As the applicant failed to commence mediation within two years of this refusal, the application for arbitration was time-barred.

The insurer applied to vary or revoke a previous arbitration decision ordering it to pay for the insured's physiotherapy treatment and interest.

The insurer argued the insured was barred from receiving benefits under s. 43(3) of the Statutory Accident Benefits Schedule because he failed to attend a Designated Assessment Centre (DAC) examination.

The arbitrator found that while the insured did fail to make himself reasonably available, this failure occurred after the physiotherapy treatment had already concluded.

Therefore, the exclusion did not apply retroactively to the completed treatment.

The arbitrator also held that the insured was entitled to interest on the overdue benefits, as the Schedule does not provide for the forfeiture of interest due to non-compliance.

The insurer's application was dismissed and interest was ordered.

The applicant was injured in a motor vehicle accident while driving his estranged wife's vehicle.

The insurer denied statutory accident benefits, arguing under s. 30(1)(a) of the Schedule that the applicant ought reasonably to have known the vehicle was uninsured.

The arbitrator found that the insurer failed to meet its evidentiary burden to show that an ordinary, rational person in the applicant's situation would have known the vehicle lacked insurance.

The preliminary issue was resolved in favour of the applicant.

The applicant's representative sought to withdraw from the arbitration proceeding on the eve of the hearing.

The insurer sought costs against the representative or the applicant.

The arbitrator found that the representative had misrepresented the circumstances of his withdrawal and that the real litigant was the assessment facility.

However, the arbitrator concluded he lacked jurisdiction under the Insurance Act to award expenses against a representative.

The arbitrator declined to award expenses against the applicant, finding him largely blameless, but ordered the applicant to withdraw the arbitration or face costs, and imposed a $3,000 penalty if the applicant commenced a future arbitration for the same assessment.

The Applicant was injured in a motor vehicle accident and sought payment for four medical assessments and reports under section 24 of the Statutory Accident Benefits Schedule.

The Insurer refused payment, arguing the reports were duplicative, deficient, or medical-legal in nature.

The Arbitrator found that the Insurer was not limited to its initial reasons for denial, but ultimately concluded that all four assessments were reasonable at the time they were requested and were obtained for the purpose of the Regulation.

The Arbitrator ordered the Insurer to pay for the assessments with interest, awarded the Applicant her arbitration expenses, and ordered a special award of 25 percent regarding two specific unpaid assessments for which the Insurer provided no reason for non-payment.

Following the dismissal of the applicant's claim for statutory accident benefits, the insurer sought its expenses of the arbitration proceeding and a $3,000 award under subsection 282(11.2) of the Insurance Act.

The arbitrator found that the applicant failed to comply with production orders, did not appear at the hearing, and commenced a proceeding that was manifestly unfounded, frivolous, and an abuse of process.

The applicant was ordered to pay the insurer's expenses of the arbitration, to be assessed, and an additional $3,000 for commencing a frivolous arbitration.