OFSCDRS 2001

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

The insurer terminated her income replacement benefits on February 4, 1998.

The applicant applied for mediation on June 16, 1999, but the application was returned by FSCO due to deficiencies.

The applicant did not correct the deficiencies until August 15, 2000, well after the two-year limitation period had expired on February 4, 2000.

The arbitrator found that the applicant failed to commence a valid mediation within the prescribed time limit and could not retroactively cure the defect to revive the original application.

The arbitration was dismissed as time-barred.

The applicant was injured in a motor vehicle accident and commenced a court action against the insurer for statutory accident benefits.

The parties settled the court action and executed a release.

The applicant subsequently applied for arbitration at the Financial Services Commission of Ontario, claiming entitlement to money deducted for Canada Pension Plan benefits during the settlement period.

The insurer raised a preliminary issue regarding jurisdiction.

The arbitrator held that the Commission lacked jurisdiction, as the applicant had elected to proceed in court under section 281(1) of the Insurance Act, and any dispute regarding the interpretation of the settlement agreement must be dealt with by the court.

The applicant was injured in a motor vehicle accident and subsequently convicted of assault for events occurring around the time of the accident.

The insurer terminated his income replacement benefits and sought repayment, arguing that subsections 30(4) and (5) of the Statutory Accident Benefits Schedule precluded him from receiving benefits due to his criminal conviction.

The arbitrator held that the exclusion in subsection 30(4) only applies to benefits payable during the period up to the time the charge is finally disposed of.

Since the applicant was seeking benefits for a period after his conviction, he was not precluded from receiving them.

The applicant was awarded the expenses of the preliminary issue hearing.

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

The applicant sought ongoing benefits, arguing that accident-related headaches, neck, and back pain prevented him from working full-time as a travel agent.

The arbitrator found that the applicant suffered a substantial inability to perform the essential tasks of his pre-accident employment due to chronic pain from soft-tissue injuries and aggravated pre-existing conditions.

The arbitrator ordered the insurer to pay ongoing income replacement benefits but denied the applicant's claim for a special award, finding the insurer's termination of benefits was not unreasonable.

Following an arbitration award for chiropractic and rehabilitation expenses, the applicants sought assessment of their arbitration expenses totaling $50,791.66.

The insurer disputed the amount, arguing the legal fees and expert disbursements were excessive.

The arbitrator assessed the expenses at $42,493.76, applying a 4:1 ratio for preparation to hearing time but reducing the fees due to the applicants' minimal success and the self-serving involvement of the rehabilitation clinic.

The arbitrator also determined that interest on the awarded benefits was payable to the husband from the date of the arbitration award (due to his failure to attend a DAC assessment) and to the wife from 14 days after the DAC assessment report.

Following a decision awarding the applicant statutory accident benefits for home renovations, the parties disputed the date from which interest should run.

The arbitrator found that the insurer's letter of December 9, 1999, clarifying its position on the renovation costs, constituted a refusal to pay under s. 24(8) of the Schedule.

The insurers were ordered to pay interest at two percent per month on the outstanding balance of $32,041 plus GST from December 9, 1999, until the obligations under the previous order were discharged.

The applicant was injured in a motor vehicle accident and received income replacement benefits until the insurer terminated them based on an orthopaedic assessment.

The applicant sought benefits for the period until he returned to full-time work, arguing that a combination of physical pain, sleep apnea, and psychological distress rendered him substantially unable to perform his sedentary job.

The arbitrator found the applicant credible and held that the accident materially contributed to his deteriorating physical and mental condition.

The arbitrator concluded the applicant was substantially disabled from performing the essential duties of his employment during the disputed period and ordered the insurer to pay the benefits with interest.

The applicant's husband died after suffering a heart attack while driving his vehicle, which subsequently veered off the road and struck a planter and a pole.

The applicant sought death benefits and funeral expenses under the Statutory Accident Benefits Schedule.

The insurer denied the claim, arguing the death was not caused by an 'accident'.

The arbitrator found that the heart attack, stemming from a pre-existing condition, was an intervening force and the direct cause of death, not the use or operation of the vehicle.

The application for arbitration was dismissed.

The Applicant was injured in a motor vehicle accident during the course of his employment and initially elected to receive workers' compensation benefits.

After his condition worsened and he underwent spinal surgeries, he withdrew his election to pursue a tort claim and claim statutory accident benefits.

The Insurer raised preliminary objections that the application was out of time under subsection 32(1) of the Schedule and that the election to sue was made primarily to claim accident benefits under section 59.

The Arbitrator dismissed both objections, finding the Applicant had a reasonable explanation for the delay and that his re-election was motivated by a genuine belief he could achieve greater recovery through a tort action.

The appellant appealed a preliminary arbitration order concerning the scope of the issue to be arbitrated.

The insurer had paid the base fee for an assessment but refused to pay a premium fee adjustment for travel time.

At arbitration, the insurer argued the appellant must prove the reasonableness of the entire account, which the arbitrator accepted.

On appeal, the Director's Delegate held that the insurer's prior payment and conduct put the reasonableness of the assessment itself beyond dispute.

The arbitrator exceeded her jurisdiction by expanding the issue.

The appeal was allowed and the matter remitted to determine only the entitlement to the premium fee adjustment.

The insurer moved to stay the applicant's arbitration hearing on the basis that she refused to attend the insurer's health care and vocational examinations.

The examinations were scheduled shortly before the hearing, and the resulting reports would not have been served within the 30-day disclosure period required by the Dispute Resolution Practice Code.

The arbitrator found that the late delivery of the reports would prejudice the applicant's ability to prepare for the hearing.

The insurer's request for the examinations was deemed unreasonable, and the motion to stay the arbitration was dismissed.

In a dispute over statutory accident benefits following a motor vehicle accident, the applicant sought production of the insurer's adjusters' notes, policy manuals, reserve documentation, and legal opinions.

The arbitrator ordered the production of adjusters' notes up to the date the application for mediation was filed, as litigation privilege generally attaches after that date.

The requests for policy manuals, reserve information, and legal opinions were denied, as reserve information is generally confidential to promote settlement, and there was no evidence that solicitor-client privilege had been waived for the legal opinions.

The applicant, who had a pre-existing dystonic tremor, was injured in a motor vehicle accident.

She claimed statutory accident benefits for caregiver expenses, attendant care, and physiotherapy, arguing the accident worsened her condition and left her unable to care for herself and her infant daughter.

The insurer denied the claims, relying on an orthopaedic surgeon's report and arguing the expenses were not 'incurred' because family members provided the care without payment.

The arbitrator found the applicant was a 'thin skull' claimant whose disability was materially contributed to by the accident.

The arbitrator held that the applicant had 'incurred' an obligation for the care provided by her family and awarded caregiver and attendant care benefits, as well as the physiotherapy claim.

Furthermore, the arbitrator found the insurer unreasonably withheld benefits and ordered a special award of 50 percent of the outstanding benefits.

The applicant was injured in a motor vehicle accident and sought various statutory accident benefits that the insurer had terminated or denied.

The arbitrator found that the applicant's ongoing chiropractic and massage therapy treatments were reasonable for pain relief, and that her physical and cognitive limitations justified the cost of taxi transportation to treatment sessions and ongoing housekeeping expenses.

However, the claim for opioid prescription medication was denied, as the weight of medical opinion indicated it was not beneficial and potentially harmful.

The arbitrator rejected the applicant's argument that her income replacement benefits should include the indexation percentage for the first year following the onset of disability, finding the statutory language clear.

Finally, the arbitrator ordered the insurer to pay a $5,000 special award for unreasonably withholding payment for treatments and medication in blatant disregard of the pay-pending-dispute provisions of the Schedule.

The applicant sought to withdraw his application for arbitration regarding statutory accident benefits after a settlement had been reached.

The insurer agreed to the withdrawal but sought costs and its assessment fee against the applicant's representative or the applicant personally, arguing the proceeding was an abuse of process.

The arbitrator held there was no jurisdiction under the Insurance Act to order costs against a representative or non-party.

The arbitrator also declined to order costs against the applicant personally, finding his conduct was not frivolous, vexatious, or an abuse of process.

The withdrawal was permitted on the condition that if the matter is brought again, the applicant must pay the insurer's assessment fee and costs.

The insurer brought a motion seeking relief from the implied undertaking rule to compel the production of the applicant's related tort file, including medical and financial documentation.

The applicant opposed the motion, arguing that the documents were protected by the deemed undertaking rule under Rule 30.1 of the Rules of Civil Procedure.

The arbitrator held that while arbitrators have the jurisdiction to grant relief from the implied undertaking rule under sections 20 and 22 of the Insurance Act, the insurer failed to demonstrate special circumstances or specific relevance to justify overcoming the presumption of privacy.

The motion for production was denied.

Following a decision denying the applicant's claim for statutory accident benefits, both parties sought their expenses for the arbitration.

The arbitrator found that the applicant had engaged in wilful misrepresentation, delayed the resolution of the matter, and abused the tribunal's process.

Consequently, the applicant was denied his expenses.

The insurer was awarded its full claimed expenses of $14,960.76, as the applicant's conduct unnecessarily prolonged and obstructed the proceedings.

The applicant sought clarification of the amount owing by the insurer for physiotherapy treatments following a previous arbitration decision.

The arbitrator determined that the previous findings only applied to physiotherapy treatments, not other services provided by the clinic.

The arbitrator calculated that the insurer owed an additional $500 for the 48 approved sessions.

Furthermore, the arbitrator held that interest at 2% per month compounded was payable on the overdue amounts from June 30, 1999, as the determination that the expenses were reasonable implies they were reasonable all along.

The applicant sought statutory accident benefits for a medical account.

The applicant failed to attend multiple pre-hearing discussions.

The applicant's representative sought to withdraw from the proceeding without providing proper notice or obtaining consent.

The arbitrator denied the representative's request to withdraw, ordered the applicant to pay costs for non-attendance, and allowed the insurer to add an issue regarding the repayment of $1,900 in previously paid benefits.

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

The applicant requested a Designated Assessment Centre (DAC) assessment, which was not performed for several years due to a dispute over whether the insurer provided the necessary Permission to Disclose forms.

The insurer argued the applicant's subsequent application for arbitration was barred by the two-year limitation period.

The Arbitrator found that the onus was on the insurer to provide the forms, which it failed to do, and therefore the limitation period did not begin to run until the DAC report was eventually released.

The application for arbitration was held to be timely.