OFSCDRS 2001

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for physiotherapy and dental treatments.

The insurer denied the claims, arguing the treatments were not reasonable and necessary.

The arbitrator found the applicant's credibility to be lacking due to numerous discrepancies in her medical history and presentation.

The arbitrator concluded that the physiotherapy at the Rehab Centre was not reasonable, as the applicant had abandoned a previous clinic without cause and showed no significant improvement.

Furthermore, the arbitrator found insufficient objective evidence to support a diagnosis of a temporomandibular joint (TMJ) disorder caused by the accident, rejecting the applicant's dental treatment claim.

The application for benefits was dismissed.

The appellant, who suffered a severe brain injury in a motor vehicle accident, appealed an arbitration decision dismissing his claim for payment of 'non-legal' rehabilitative services provided by a law clerk at his legal counsel's firm.

The arbitrator had found that the claim was not proven because the law clerk's dockets did not reliably distinguish between legal and non-legal services, and that the services were redundant given the extensive support provided by the appellant's professional case manager.

The Director's Delegate dismissed the appeal, finding no error in the arbitrator's assessment of the evidence and concluding that the arbitrator reasonably found the expense to be unproven and unnecessary.

The applicant, a visiting mental health nurse, was injured in a motor vehicle accident and received income replacement benefits.

She attempted a graduated return-to-work program coordinated by the insurer, but struggled with physical pain and psychological difficulties.

The insurer terminated her benefits based on assessments indicating she was no longer physically disabled.

The arbitrator found that while the applicant was physically capable of performing most tasks, the demanding and stressful nature of her job, which involved treating acutely psychotic patients alone in the community, meant she was substantially disabled by her accident-related depression.

The arbitrator awarded ongoing income replacement benefits, certain medical and rehabilitation expenses, but denied the applicant's claim for a special award and the insurer's claim for repayment of benefits.

The insurer appealed an arbitration order requiring it to pay transportation expenses for a minor insured who was driven to medical appointments by her parents in their own vehicles.

The trips were all under 50 kilometres.

The Director's Delegate allowed the appeal, finding that the 50-kilometre exemption in s. 14(6) of the SABS-96 and the Transportation Expenses Guideline applied to trips taken in a family vehicle.

The insurer was not liable for the transportation expenses.

The appellant appealed an arbitration order that denied his claim for increased income replacement benefits based on alleged self-employment income.

The appellant had no pre-accident business records and relied on undated letters from customers, mostly family and friends, to prove his income from handyman jobs.

The arbitrator found the evidence insufficient and unreliable to establish his pre-accident self-employment income.

On appeal, the Director's Delegate upheld the arbitrator's decision, finding no error of law in her assessment of the evidence and credibility.

The appeal was dismissed.

The applicant was injured in a motor vehicle accident and received income replacement benefits until they were terminated by the insurer.

The applicant brought a motion for interim benefits pending the arbitration hearing and sought production of the insurer's claims file.

The arbitrator found that the applicant failed to attend a scheduled insurer examination, entitling the insurer to suspend benefits for that period.

The arbitrator dismissed the motion for interim benefits, finding the applicant had not established a prima facie case for entitlement given the conflicting medical evidence and lack of cross-examination.

The arbitrator also made several production orders, requiring the applicant to produce medical records from one year pre-accident and the insurer to produce non-privileged portions of its claims file.

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

In a previous decision, the arbitrator found that the applicant knew he was operating an uninsured vehicle and ordered him to repay income replacement benefits.

Both parties sought expenses for the arbitration proceeding.

The arbitrator found that the applicant's evidence regarding his knowledge of the lack of insurance was untruthful and fraudulent.

Consequently, the applicant was denied his expenses, and the insurer was awarded its reasonable expenses of $2,712.50 plus $59 in disbursements.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits, including income replacement benefits and supplementary medical expenses.

The insurer terminated her income replacement benefits, arguing she had recovered and could return to her pre-accident employment as a meat packer.

The arbitrator found that the applicant suffered from chronic pain syndrome and a major depressive disorder caused by the accident, rendering her substantially unable to perform the essential tasks of her employment.

The arbitrator preferred the evidence of the applicant's treating practitioners and experts over the insurer's assessors.

The applicant was awarded ongoing income replacement benefits, supplementary medical expenses, and interest on overdue benefits.

The Insurer requested the dismissal of the arbitration proceeding because the Applicant failed to meet undertakings.

The Applicant, having retained a new representative just days before the hearing, requested an adjournment.

The Arbitrator declined to dismiss the proceeding, finding it too drastic a remedy, but granted the adjournment peremptory to the Applicant.

The Arbitrator awarded the Insurer $1,000 in costs thrown away due to the late adjournment request and the Applicant's failure to comply with productions, and imposed strict timelines for future productions and expert reports.

The applicants sought their expenses following an arbitration regarding statutory accident benefits.

The arbitrator found that the applicants were entitled to their arbitration expenses because the factual and legal issues raised were complex, novel, and significant, acting as a 'test case' for several other similar arbitrations.

The insurer's offer to settle was not given weight as it was ambiguous and made for tactical advantage rather than genuine settlement.

The Applicant was injured in a motor vehicle accident and sought income replacement benefits after the Insurer terminated them.

The Insurer argued the Applicant could return to her pre-accident employment as a bartender.

The Arbitrator found the Applicant suffered a Grade II whiplash injury and was substantially unable to perform the essential tasks of her demanding pre-accident job, which included repetitive bending, reaching, and lifting.

The Applicant was awarded income replacement benefits and interest, but was ordered to pay the Insurer's arbitration expenses for the first day of the hearing due to her failure to appear.

The applicant was injured while riding as a passenger on a streetcar and applied for statutory accident benefits, including non-earner benefits, housekeeping expenses, and transportation expenses.

The insurer denied the claims, and the applicant sought arbitration.

The arbitrator dismissed the applicant's claims, finding that medical evidence and surveillance contradicted his assertions of ongoing impairment and inability to perform pre-accident activities.

The arbitrator also found the applicant's evidence regarding transportation expenses unreliable.

Although the arbitrator declined to impose a penalty for a frivolous or vexatious proceeding, he awarded the insurer $1,250 in expenses because the applicant's claims were manifestly unfounded.

The insurer appealed an arbitrator's decision awarding the insured his full arbitration expenses.

The insurer had been largely successful at the arbitration and had made a qualifying offer to settle prior to the hearing.

The Director's Delegate found that the arbitrator erred in law by misapprehending the terms of the settlement offer, mistakenly believing it required the insured to give up all future benefits.

In reassessing the expenses, the Director's Delegate noted that while the insurer's offer was serious and the insurer was mostly successful, the insured's case had some merit based on the medical evidence.

The appeal was allowed in part, and the expenses award was varied to entitle the insured to two-thirds of his reasonable arbitration expenses.

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

The parties entered into a settlement agreement, but a dispute arose over the interpretation of a term regarding ongoing payment for a shop assistant and housekeeping expenses.

The arbitrator held that the settlement agreement implicitly required the applicant to demonstrate continuing entitlement to the benefits and to provide reasonable verification of her expenses, rather than providing a 'blank cheque' for life.

The applicant sought to re-open the arbitration hearing to admit new evidence regarding whether medical assessments could be billed to OHIP.

The arbitrator treated the request as a motion.

Applying the Palmer test for the admission of new evidence, the arbitrator found that the applicant failed to meet the due diligence requirement, as the representative conceded the evidence could have been obtained prior to the hearing with greater diligence.

The motion to re-open the hearing was dismissed.

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

A preliminary issue was raised regarding whether short-term disability payments received under the Workplace Safety and Insurance Act prior to the accident should be considered 'income from employment' for calculating his weekly income replacement benefits.

The arbitrator held that such payments do constitute 'income from employment' under the Statutory Accident Benefits Schedule, applying a purposive interpretation to avoid the absurdity of excluding them while allowing their deduction post-accident.

The appellant appealed an arbitration order that denied her further weekly income benefits and required her to pay half of the insurer's arbitration expenses.

The appellant argued she was denied a fair hearing due to the arbitrator's procedural rulings (dismissing an interpreter and refusing to consider a second accident), her counsel's incompetence, and the arbitrator's alleged bias stemming from frustration with her counsel.

The Director's Delegate dismissed the appeal, finding that the absence of an interpreter did not prejudice the appellant, the arbitrator correctly refused to hear the unmediated second accident claim, the Charter right to effective counsel does not apply to private economic disputes, and the arbitrator's frustration with counsel's delays did not amount to bias.

The applicant was injured in a motor vehicle accident when he was nine years old.

Upon turning sixteen, he applied for statutory accident benefits.

The insurer denied the claim, arguing that because more than 156 weeks had passed since the accident, the more onerous post-156 week test applied.

The applicant argued that the pre-156 week test should apply initially upon his turning sixteen.

The arbitrator held that the pre-156 week test under subsection 13(1) of the Schedule applies first when an insured turns sixteen, regardless of the time elapsed since the accident, to avoid anomalous results based on the insured's age at the time of the accident.

The applicant sought an assessment of her expenses following an arbitration regarding statutory accident benefits where she was awarded a special award and interim benefits.

The insurer disputed the number of hours claimed and the hourly rate of $150.

The arbitrator found that the 42.75 hours claimed by the applicant's counsel were reasonable, noting that extensive preparation time resulted in a settlement and a significant special award, thereby decreasing hearing time.

The arbitrator also approved the maximum hourly rate of $150 given counsel's year of call and expertise.

The applicant was awarded $6,412.50 in legal fees and $466 in disbursements, plus GST.

The applicant sought statutory accident benefits following an incident where a limousine he was riding in allegedly drove over a curb.

The insurer terminated his income replacement benefits and sought repayment of all benefits paid, alleging the accident never occurred or the applicant was not injured.

The arbitrator found that the accident did occur and the insurer was not entitled to repayment.

However, the arbitrator dismissed the applicant's claim for ongoing income replacement benefits and further treatment, finding that his injuries from the subject accident had largely resolved and his ongoing disability was attributable to a subsequent accident.

The insurer was ordered to pay for two medical reports.