OFSCDRS 2001

The appellant appealed an arbitrator's decision denying payment for an in-home assessment following a motor vehicle accident.

The appellant argued that the insurer should be restricted to the reasons for denial set out in its initial notice, and alternatively, that there was sufficient evidence the assessment was for the purpose of the Statutory Accident Benefits Schedule.

The Director's Delegate dismissed the appeal, holding that an insurer is not strictly limited to its initial reasons for denial, provided there is fair disclosure and no undue prejudice.

Furthermore, the Director's Delegate upheld the arbitrator's finding that the appellant failed to provide sufficient evidence demonstrating that the assessment report was intended to be used for a treatment plan or other rehabilitation purpose under the Regulation.

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

At the arbitration hearing, the applicant's representative brought preliminary motions alleging institutional bias against FSCO, requesting an adjournment pending an appeal in another case, and seeking the appointment of a private arbitrator.

The arbitrator dismissed the preliminary motions, finding no evidence of bias and no authority to appoint a private arbitrator.

The applicant's representative then alleged personal bias against the arbitrator and refused to proceed with the hearing on the merits.

The arbitrator dismissed the substantive claims for want of evidence and ordered the applicant to pay $1,000 towards the insurer's expenses and assessment fee due to the representative's disruptive and unfounded conduct.

Following a preliminary issue hearing where the insurer successfully argued the applicant was not an insured person, the applicant sought her arbitration expenses.

The arbitrator found that the application was brought in good faith on a novel and significant issue of interpretation, which outweighed the insurer's ultimate success.

The applicant was awarded expenses fixed at $9,197.93, with deductions made for certain pre-arbitration fees, an unnecessary airline ticket for the applicant's mother, and unallowable travel disbursements.

The applicant, a pedestrian injured in a motor vehicle accident, applied for income replacement benefits and non-earner benefits.

He claimed he had two future contracts of employment made before the accident.

The arbitrator found the applicant's evidence regarding the employment contracts to be fabricated, illogical, and inconsistent, concluding he did not meet the eligibility criteria for income replacement benefits.

The claim for non-earner benefits was also dismissed as the medical evidence and the applicant's continued university attendance did not support a complete inability to carry on a normal life.

The applicant was ordered to pay the insurer's arbitration expenses due to his conduct and fabrication of evidence.

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

The insurer terminated her income replacement benefits, prompting the applicant to apply for arbitration.

Shortly before the hearing, the insurer reinstated the benefits and paid the arrears with interest.

The arbitration proceeded solely on the issue of whether the applicant was entitled to a special award under s. 282(10) of the Insurance Act.

The arbitrator found that the insurer acted unreasonably and engaged in flagrant misconduct by terminating benefits without meaningful medical evidence, ignoring overwhelming medical reports from its own assessors confirming the applicant's severe depression and disability, and improperly deducting collateral benefits.

The arbitrator awarded the maximum special award of 50% of the withheld benefits, amounting to $61,829.52.

The applicant was injured in a motor vehicle accident while traveling between clients for her employment.

She applied for statutory accident benefits, but the insurer refused payment, arguing she was entitled to workers' compensation benefits and had elected to bring a tort action primarily to claim accident benefits under section 59 of the Statutory Accident Benefits Schedule.

The arbitrator found that the applicant did not commence her tort action primarily for the purpose of claiming statutory accident benefits, and therefore she was not precluded from proceeding to arbitration.

The applicant was injured in a motor vehicle accident and applied for statutory accident benefits, including income replacement benefits (IRBs) and housekeeping expenses.

The insurer denied the claims.

At arbitration, the central issue was whether the applicant was an employee or self-employed, which dictated the information required to calculate his IRB.

The arbitrator found the applicant was self-employed and had failed to provide the necessary financial information to calculate the benefit, disentitling him to IRBs under section 33 of the SABS-1996.

However, the arbitrator awarded housekeeping expenses based on medical evidence of his impairments and ordered the insurer to pay the applicant's arbitration expenses.

Surveillance evidence obtained deceptively by the insurer was excluded.

The appellant appealed an arbitration decision that terminated her weekly income benefits and ordered her to repay a portion of her psychological treatment costs.

On a preliminary motion, the appellant sought an order requiring the insurer to provide full transcripts of the arbitration hearing and to admit fresh evidence.

The Director's Delegate ordered the insurer to arrange and pay for the transcription of the untranscribed portions of the treating psychologist's testimony, finding it necessary for a fair hearing of the appeal.

The motion to admit fresh evidence was dismissed, except for a Canada Pension Plan Review Tribunal decision, which was admitted.

The applicant, an elderly pedestrian, sustained a closed head injury when struck by a vehicle.

She claimed statutory accident benefits for care-giving services provided by her daughter and travel expenses for her granddaughter.

The arbitrator found that the accident materially contributed to the applicant's cognitive impairments.

However, applying the Court of Appeal's decision in Monochino, the arbitrator held that the applicant was not entitled to care-giver benefits because her daughter did not lose income and did not qualify as a professional care-giver.

The claim for travel expenses was dismissed as the trip was not for the applicant's benefit.

The claim for a special award was also dismissed.

The applicant was injured in a motor vehicle accident and received income replacement benefits until the insurer terminated them at the 104-week mark, asserting she could return to work in alternative occupations.

The applicant brought a motion for interim benefits pending the full arbitration hearing.

The arbitrator reviewed the standard for interim benefits, noting it requires establishing a prima facie case and urgency.

The arbitrator found that the applicant's entitlement raised difficult questions of law regarding the "complete inability" test that should be determined at a full hearing.

Furthermore, the applicant failed to establish sufficient urgency, as the hearing was scheduled to begin in three months.

The motion for interim benefits was dismissed.

The applicant sought to add a dispute over a $5,000 treatment plan to an ongoing arbitration for statutory accident benefits.

The insurer objected, arguing the issue had not been mediated and that previous arbitrators had already denied requests to add it.

The arbitrator applied the doctrine of res judicata, finding that a prior arbitrator had already made a final determination that the issue had not been mediated and could not be added.

The request to add the issue was denied.

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

The insurer terminated medical benefits based on an independent medical examination.

Over two years later, the applicant's lawyer arranged for functional abilities and orthopaedic assessments without the insurer's approval.

The insurer refused to pay the $2,568 cost of these assessments.

The arbitrator found that the applicant failed to prove the assessments were reasonably incurred for the purposes of the Schedule, noting the lack of medical evidence supporting the need for the assessments and the long period of inactivity on the file.

The claim for the cost of examinations and a special award was dismissed.

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

She applied for arbitration seeking ongoing IRBs, housekeeping expenses, and a special award.

The arbitrator found that the applicant suffered from physical and psychological impairments, including post-traumatic stress disorder and chronic pain, caused by the accident.

The arbitrator concluded that she suffered a substantial inability to perform the essential tasks of her pre-accident employment as a fabric cutter and awarded ongoing IRBs.

Housekeeping expenses were partially awarded for the initial period following the accident.

The claim for a special award was dismissed, and the issue of repayment was deferred.

The Applicant sought expenses for an arbitration hearing regarding statutory accident benefits.

The Applicant was represented by her son, an untrained agent.

The Arbitrator fixed the agent's hourly rate at the maximum of $23 and applied a ratio of 2.5 to the 13 hours of hearing time to determine preparation time, allowing 45.5 hours total.

After reducing certain disbursements, the total expenses were fixed at $1,681.09.

Because the Insurer had already paid $1,710.00 towards expenses, the Arbitrator ordered that no further expenses were outstanding.

The applicant was injured in a motor vehicle accident and her claims for statutory accident benefits were dismissed in a prior decision.

The insurer sought its expenses for the arbitration proceeding.

The arbitrator found that the applicant's representative's conduct hindered the proceeding and that the application had little merit.

Applying the criteria under the Expense Regulation, the arbitrator ordered the applicant to pay the insurer's expenses, assessed at $2,461.99.

The applicant was involved in two motor vehicle accidents in April 2000.

She applied for statutory accident benefits from RBC Insurance for the first accident and from TTC Insurance for the second.

TTC argued that the applicant was required to claim benefits from RBC as the spouse of a named insured under section 268(5) of the Insurance Act.

The arbitrator held that the issue of whether the applicant was a spouse under the RBC policy was a priority dispute outside the jurisdiction of the Financial Services Commission of Ontario.

Pending resolution of the priority dispute in the proper forum, TTC, as the first insurer to receive the completed application for the second accident, was responsible for paying the benefits.

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

She later signed a full and final release.

Over a year later, she underwent five health care assessments and sought reimbursement from the insurer.

The insurer denied the claims, initially relying on the release but later withdrawing that defence.

The arbitrator found that the applicant had recovered from her accident injuries at the time of the assessments and that her ongoing issues were due to pre-existing work-related hand injuries.

The assessments were deemed not reasonable expenses for the purpose of the Regulation.

The claim for a special award was also dismissed, as the insurer acted reasonably in relying on the release before the law changed.

The applicant was injured in a motor vehicle accident and sought arbitration for unpaid physiotherapy and functional abilities evaluation expenses.

At the pre-hearing, the applicant's representative sought permission to withdraw because the applicant failed to pay a requested retainer.

The arbitrator permitted the withdrawal.

The applicant, who stated he did not understand the proceedings, agreed to the dismissal of his application provided the insurer's costs were limited to $50.

The arbitrator dismissed the application and ordered the applicant to pay $50 in costs.

Following a preliminary issues hearing where the applicant was precluded from proceeding to arbitration due to limitation periods and failure to submit forms, the arbitrator determined the quantum of expenses payable to the insurer.

The applicant failed to respond to the insurer's Bill of Costs or the Commission's requests for submissions.

The arbitrator assessed the insurer's expenses at $2,656.49, finding the amount reasonable given the complexity of the preliminary issues and the applicant's conduct, which had previously been found to constitute an abuse of process.

The applicant sought to vary or revoke an appeal decision that confirmed an arbitrator's order denying his claim for income replacement benefits.

The denial was based on the applicant driving with a suspended licence at the time of the accident due to unpaid fines.

The applicant argued there was new evidence and an error in the order.

The Director of Arbitrations found that the 'new' evidence was available prior to the arbitration and confirmed the licence suspension.

The Director also found no error in the previous order regarding the insurer's late raising of the exclusion issue.

The application for variation/revocation was dismissed, and the applicant was ordered to pay expenses.