OFSCDRS 2002

The applicant sustained a permanent knee injury in a motor vehicle accident and sought ongoing income replacement benefits and funding for university retraining as an engineer.

The insurer terminated benefits based on a vocational assessment identifying alternative employment.

The arbitrator found the insurer's job recommendations unsuitable due to the applicant's physical limitations and pre-accident earnings, and drew an adverse inference against the insurer for failing to arrange a required Designated Assessment Centre evaluation.

The applicant was awarded ongoing income replacement benefits, but his claim for engineering retraining was dismissed as it was not similar to his pre-accident employment as a roofing supervisor.

The applicant was injured in a motor vehicle accident and sought physiotherapy expenses.

The insurer raised a preliminary issue, arguing the applicant was precluded from proceeding to mediation under s. 71(1) of the Statutory Accident Benefits Schedule because he failed to attend a Designated Assessment Centre (DAC) assessment in 1996.

The arbitrator found that the insurer failed to schedule the assessment at the closest DAC and failed to obtain the required s. 37 certificate.

As the requested assessment was not authorized under the Schedule, the applicant did not fail to make himself reasonably available and was not precluded from proceeding to mediation.

The preliminary issue was dismissed.

The applicant sought to withdraw her application for arbitration regarding a dispute over an $83.87 disability certificate, citing alleged institutional bias.

The insurer consented to the withdrawal but sought its expenses and the $3,000 assessment fee, arguing the proceeding was frivolous, vexatious, and an abuse of process.

The arbitrator permitted the withdrawal but ordered the applicant to pay the insurer's legal expenses of $1,151.44 and the $3,000 assessment fee, finding that the application was part of a larger course of improper conduct designed to harass the insurer and was therefore an abuse of process.

The applicant was injured in a motor vehicle accident and sought income replacement benefits, housekeeping expenses, and the cost of a gym membership.

The arbitrator found that the medical evidence did not support a substantial inability to perform the essential tasks of his employment during the claimed period.

The claims for housekeeping and the gym membership were also dismissed due to lack of credible evidence and medical necessity.

The applicant was ordered to repay the insurer for an overpayment of benefits received while he was also receiving long-term disability benefits.

The insured was involved in a motor vehicle accident and received weekly income benefits.

A dispute arose regarding her entitlement to benefits beyond the 156-week mark and whether she had been overpaid due to the receipt of collateral benefits.

At arbitration, the insured argued for the first time during final submissions that her collateral benefits were not deductible.

The Arbitrator agreed and ordered the insurer to pay additional benefits.

On appeal, the Director of Arbitrations held that the Arbitrator erred in deciding the deductibility issue without giving the insurer an adequate opportunity to respond, as it was raised too late and constituted a denial of fairness.

The insurer's appeal was allowed, and the insured's appeal regarding interest was dismissed.

The applicant failed to appear at the arbitration hearing regarding her claim for statutory accident benefits.

The arbitrator proceeded with the hearing in her absence but added a preliminary issue of whether the applicant is entitled to have the hearing reopened.

Noting concerns about the applicant's representation, address, language barriers, and potential cost consequences, the arbitrator ordered that the applicant may file submissions by January 13, 2003, to reopen the hearing, failing which a decision would be issued based on the evidence presented by the insurer.

The insurer appealed an arbitration order requiring it to pay ongoing income replacement benefits.

The insurer had terminated the insured's benefits based on an insurer examination (IE) report, despite having received a Designated Assessment Centre (DAC) report that supported the insured's disability claim.

The Director's Delegate dismissed the appeal, holding that under section 37(5) of the SABS-1996, an insurer cannot terminate benefits based on an IE report in the face of a positive DAC report, but must instead continue paying benefits pending the resolution of the dispute.

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

During the pre-hearing process, the arbitrator raised concerns regarding the competence and conduct of the applicant's non-lawyer representatives.

The representatives failed to comply with multiple directions, including providing a signed acknowledgment regarding their status and the applicant's potential liability for expenses.

The arbitrator found that the representatives were not competent, failed to comply with their duties, and were impeding the applicant's access to justice.

Pursuant to section 23(3) of the Statutory Powers Procedure Act, the representatives were excluded from the proceeding.

The insurer was awarded $1,632.99 in expenses, payable as a setoff against any future award to the applicant regarding the disputed treatment plans.

The moving parties, a law firm and its lawyer, brought a motion to withdraw as solicitors of record for the applicant in an ongoing statutory accident benefits arbitration, citing an irrevocable breakdown in the solicitor-client relationship.

The applicant opposed the withdrawal, arguing prejudice due to the significant delay in the proceedings, which stemmed from 1993 motor vehicle accidents.

The arbitrator first determined, based on psychiatric evidence, that the applicant possessed the capacity to instruct counsel.

The arbitrator then found that while he had no authority to force a solicitor to continue representing a client against their will, he could impose conditions on the withdrawal to mitigate prejudice under Rule 9.8 of the Dispute Resolution Practice Code.

The motion to withdraw was granted, subject to conditions including that the law firm provide a different lawyer to act as amicus curiae at the upcoming hearing.

Expenses for a previously adjourned hearing were awarded against the moving parties.

The insurer brought a motion to stay the arbitration hearing until the applicant attended two insurer's examinations (orthopaedic and psychological/neuropsychological) and to compel the production of raw test data from the applicant's psychologist.

The arbitrator dismissed the request for the examinations, finding the insurer failed to prove they were reasonably necessary, as the applicant had not been treated by an orthopaedic surgeon and was not claiming a brain injury.

However, the arbitrator ordered the production of the raw test data to a psychologist retained by the insurer or directly to the insurer's counsel.

The applicants, a husband and wife who lived and worked on a farm together, were both injured in a motor vehicle accident and applied for statutory accident benefits.

Disputes arose with the insurer, and both applicants filed applications for arbitration.

The parties consented to combining the applications.

The arbitrator found that because the applicants' duties with respect to their home and farm were intertwined, there were common issues of fact and law, and combining the claims would be the most just, quickest, and least expensive means to deal with the applications pursuant to Rule 30 of the Dispute Resolution Practice Code.

The applications were ordered to be combined.

The applicant sought to withdraw his Application for Arbitration regarding statutory accident benefits to pursue the claim in Small Claims Court, citing alleged institutional bias of FSCO arbitrators.

The insurer sought terms for the withdrawal, including repayment of its $3,000 assessment fee and hearing expenses.

The arbitrator permitted the withdrawal but ordered the applicant to pay $2,000 in hearing expenses to the insurer due to the applicant's representative prolonging the proceeding with a manifestly unfounded bias application.

The insurer's request for repayment of the assessment fee was denied as the application was not frivolous or vexatious when commenced.

The appellant appealed an arbitration decision that denied his claim for income replacement benefits and limited his housekeeping and home maintenance expenses to $100 per week.

The appellant argued he was self-employed as a property developer and manager, but the Director's Delegate upheld the Arbitrator's finding that he was not employed and earned no income at the time of the accident.

The Delegate also upheld the $100 weekly cap on housekeeping expenses.

However, the appeal regarding arbitration expenses was allowed in part, reducing the costs awarded to the respondent by $500 to account for the appellant's initial success before settlement offers were made.

The applicant sought an income replacement benefit following a motor vehicle accident, claiming he was employed at an auto body shop and paid in cash.

The arbitrator dismissed the claim, finding the applicant lacked credibility and failed to provide objective, verifiable evidence of his employment or his alleged substantial disability.

The arbitrator noted significant discrepancies regarding when the applicant began working, how he was paid, and his earnings.

The applicant's claim for a special award was also dismissed.

Given the frivolous nature of the proceeding and the applicant's lack of credibility, the arbitrator ordered the applicant to pay the insurer's reasonable arbitration expenses.

The applicant was injured in a motor vehicle accident and sought income replacement benefits and medical benefits after the insurer terminated them.

The arbitrator found that the applicant was entitled to income replacement benefits for a limited period from July 22, 2000, to October 4, 2000, based on his family doctor's evidence of ongoing improvement.

However, relying on surveillance evidence and a Med Rehab DAC assessment, the arbitrator concluded the applicant was substantially able to perform his pre-accident employment as a welder after October 4, 2000.

The arbitrator also awarded $1,522 for chiropractic treatments but denied the claim for physiotherapy and massage treatments, finding them not reasonable and necessary.

Following a settlement of all outstanding issues except expenses in a motor vehicle accident benefits arbitration, the applicant sought her costs of the proceeding.

The arbitrator assessed the legal fees and disbursements claimed by the applicant's two successive counsel.

Applying the criteria under the Insurance Act and the Dispute Resolution Practice Code, the arbitrator reduced the claimed hours and hourly rates, ultimately awarding $18,533.20 in legal fees and $9,968.09 in disbursements, plus applicable GST.

The insurer brought a motion for expenses against the applicant's representative, who had commenced an arbitration in the name of a minor without proper authority.

The arbitrator found that the representative was the true applicant and that bringing the unauthorized application constituted an abuse of process.

The arbitrator ordered the representative to personally pay the insurer's expenses of $4,925.38.

The applicant was involved in a motor vehicle accident when a truck collided with the trailer she was towing.

After pulling over, she ran towards the other vehicles to check on her friends and fell, injuring her arm.

The insurer denied statutory accident benefits, arguing her injuries were not directly caused by the use or operation of an automobile.

The arbitrator found that the applicant was injured in an 'accident' within the meaning of section 2(1) of the Schedule, as her actions in running between vehicles at the scene were a normal and foreseeable risk of motoring, and the use of the vehicles was a direct cause of her injuries.

The applicant applied for arbitration seeking statutory accident benefits following a motor vehicle accident.

The applicant failed to attend the hearing or communicate with his counsel, the insurer, or the Commission.

The arbitrator dismissed the applicant's claims in their entirety due to a lack of evidence.

The insurer's claim for repayment of $2,447.72 in overpaid income replacement benefits was granted.

The arbitrator also ordered the applicant to pay the insurer's arbitration expenses of $1,742.00 and an additional $1,000 for abuse of process, finding that the applicant's failure to participate unnecessarily prolonged the proceedings.

The applicant was injured in a motor vehicle accident and claimed statutory accident benefits, including caregiver and housekeeping benefits, as well as medical expenses.

The insurer denied the claims, arguing the applicant was not the primary caregiver and that the expenses were not reasonable or necessary.

The arbitrator dismissed the applicant's claims, finding her evidence regarding the payment for caregiving and housekeeping services to be imprecise and inconsistent, thus failing to prove she incurred the expenses.

The claims for medical expenses were also dismissed as the applicant failed to prove how much OHIP would contribute.

The insurer's request for repayment of its assessment fee was denied because the application was not found to be frivolous or vexatious from the outset.