OFSCDRS 2002

The applicant was injured in a motor vehicle accident and sought statutory accident benefits, including income replacement benefits, medical benefits for physiotherapy and chiropractic treatment, and expenses for treatment plans and family physician fees.

The insurer terminated income replacement benefits based on an orthopaedic assessment and disputed the other claims.

The arbitrator dismissed the applicant's claims, finding insufficient evidence to support her inability to work or the necessity of the disputed medical expenses.

The arbitrator also dismissed the insurer's claim for repayment of its assessment fee, concluding the arbitration was not frivolous or vexatious from the outset.

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

The insurer terminated benefits, arguing the applicant was not substantially disabled.

The arbitrator found the applicant lacked credibility, noting numerous inconsistencies in his medical history, functional abilities, and income reporting, which were further undermined by surveillance evidence showing him working and moving without apparent difficulty.

The arbitrator concluded the applicant did not suffer significant physical or psychological injuries as a result of the accident and dismissed all claims.

The applicant was injured in a motor vehicle accident and sought medical rehabilitation benefits for treatments received between June 1998 and October 2001.

The insurer argued the claim was barred by res judicata due to a prior arbitration decision that denied benefits for an earlier period.

The arbitrator rejected the res judicata argument, finding that entitlement to medical benefits can arise at any time and the issues were not identical.

On the merits, the arbitrator found the applicant's ongoing chiropractic, acupuncture, osteopathic, and massage treatments were reasonable and necessary to manage his symptoms and allow him to work.

The claim for prescription expenses was denied due to lack of evidence.

Following a settlement of a statutory accident benefits claim for $85,000 plus expenses, the parties could not agree on the quantum of expenses.

The applicant claimed approximately $33,000 in legal fees and disbursements.

The arbitrator assessed the expenses by applying the criteria in the Dispute Resolution Practice Code and the Expense Regulation.

The arbitrator reduced the hours claimed due to late delivery of medical reports and time thrown away by a change of counsel, but allowed the maximum hourly rate of $150 for the applicant's senior counsel due to the excellent result achieved.

The insurer was ordered to pay $20,913.68 in expenses.

The deceased was killed in a motor vehicle accident.

The insurer paid a $10,000 death benefit to her mother, but refused to make an additional payment to her father, arguing the Statutory Accident Benefits Schedule provided for a single payment.

The arbitrator ordered the insurer to pay an additional $10,000 to the father.

On appeal, the Director's Delegate confirmed the arbitrator's decision, holding that each person in respect of whom the insured was a dependant is entitled to a separate $10,000 payment.

The applicant fractured his hand when a trailer he was manually pulling to hook up to his van rolled and crushed his hand against a wall.

The insurer denied statutory accident benefits, arguing the incident was not an 'automobile accident' because the trailer was not an 'automobile' and the slip-and-fall was an intervening cause.

The arbitrator found that the trailer was being 'used in connection with' the van, bringing it within the policy's definition of an automobile.

The arbitrator concluded that the applicant was involved in an automobile accident and his impairments arose directly from the use or operation of an automobile.

The applicant, who sustained catastrophic impairments in a motor vehicle accident, sought interim attendant care benefits for a period of hospitalization and interest on overdue attendant care benefits.

The arbitrator dismissed the claim for interim benefits, finding that the applicant failed to establish a prima facie case, urgency, or a blatant disregard for the Insurance Act by the insurer.

However, the arbitrator ordered the insurer to pay interest on previously agreed attendant care benefits, as the payment was overdue.

The insurer brought a motion to stay the arbitration proceedings because the applicant failed to attend scheduled insurer's medical examinations with a physiatrist and a psychiatrist under section 42 of the Statutory Accident Benefits Schedule.

The arbitrator found that the requested examinations were reasonable and necessary to assess the applicant's ongoing claim for income replacement benefits past the 104-week mark, especially given a newly disclosed potential psychological component.

The applicant failed to provide a reasonable excuse for non-attendance.

The arbitrator ordered that the arbitration be stayed unless the applicant makes herself reasonably available for the examinations.

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

A preliminary issue hearing was scheduled to determine if the applicant was precluded from proceeding to arbitration for failing to attend an insurer examination.

Neither the applicant nor her representative attended the hearing.

The arbitrator noted discrepancies in the applicant's signatures on various documents, raising concerns that the arbitration may have been commenced without her knowledge or consent.

The arbitrator stayed the arbitration pending a determination of who actually commenced the proceeding and denied the representative's request to unilaterally withdraw.

The applicant, a taxi driver, was stabbed by a passenger during a robbery and applied for statutory accident benefits.

The insurer initially paid income replacement benefits but later terminated them, arguing the incident was not an 'accident' under the Schedule.

The arbitrator found that the event setting the chain of causation in motion was an assault, not the use or operation of an automobile, and therefore the applicant was not involved in an 'accident'.

The arbitrator also held that the insurer did not waive its right to deny coverage by initially paying benefits, as there was no conscious intention to abandon a known right.

The applicant was injured in a motor vehicle accident and received caregiver benefits, which the insurer subsequently terminated.

The applicant requested a Designated Assessment Centre (DAC) assessment but failed to attend or remain for scheduled appointments.

The Arbitrator found that the applicant did not make herself reasonably available for the assessment, rejecting her explanations regarding her mental state and lack of written notice.

As a result, the applicant was precluded from receiving caregiver benefits from the date of termination until she attends a DAC assessment, and barred from pursuing her claim at the upcoming arbitration if she fails to attend before then.

The appellant appealed an Arbitrator's decision dismissing his claim for statutory accident benefits and ordering him to pay half of the insurer's arbitration expenses.

The central issue at arbitration was whether the appellant was injured on a TTC bus or a subway train, with the Arbitrator finding his uncorroborated evidence inconsistent and unreliable.

On appeal, the Director's Delegate refused to admit new medical evidence and found no errors of law in the Arbitrator's credibility findings, application of the burden of proof, rejection of the estoppel argument, or award of expenses.

The appeal was dismissed and the appellant was ordered to pay $500 in appeal expenses.

The applicant's counsel brought a motion to withdraw from the record in a statutory accident benefits arbitration, citing a breakdown in the solicitor-client relationship and an inability to contact the applicant.

The insurer did not oppose the withdrawal but brought a cross-motion to dismiss the arbitration as frivolous and vexatious and for costs.

The arbitrator granted the counsel's motion to withdraw, finding the procedural requirements were met.

The insurer's motion to dismiss was found to be premature and could not be entertained because the applicant had not been given notice of it.

The Estate of Mark Green applied for arbitration claiming income replacement benefits following a motor vehicle accident.

Shortly before the hearing, the Estate requested to withdraw its application, citing economic non-viability.

The insurer opposed withdrawal without conditions, arguing the application was frivolous and an abuse of process because the Estate never provided basic documentation to support the claim and the deceased was not employed at the time of the accident.

The Arbitrator allowed the withdrawal but ordered the Estate to pay the insurer's $3,000 assessment fee and reasonable legal expenses, finding the application was devoid of merit when commenced and constituted an abuse of process.

The insurer brought a motion for the production of financial records from the applicant's related businesses to determine her entitlement to income replacement benefits following a motor vehicle accident.

During the hearing, the parties agreed on the specific documents to be produced, leaving only the issue of expenses.

The arbitrator found that the applicant had previously offered to produce the relevant documents and that the insurer's motion was unnecessary.

The insurer was ordered to pay the applicant's expenses, assessed at $250.

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

He was also convicted of assault arising from an altercation that occurred immediately prior to the accident.

The insurer terminated benefits and sought repayment, arguing the applicant was excluded under the criminal offence provisions of the Statutory Accident Benefits Schedule.

The arbitrator found that the assault continued at the time of the accident, triggering the exclusion.

The arbitrator rejected the applicant's arguments of waiver and estoppel, ordering the applicant to repay $6,487.19 in benefits to the insurer.

The applicant, a 66-year-old pedestrian, was struck by a motor vehicle and suffered a fractured leg.

She applied for statutory accident benefits, including non-earner, attendant care, and housekeeping benefits.

The insurer denied the non-earner benefits and disputed the quantum of the other benefits.

The arbitrator found that the applicant suffered a complete inability to carry on a normal life and awarded non-earner benefits.

The arbitrator also awarded increased attendant care and housekeeping benefits, finding the applicant was substantially unable to perform her pre-accident activities.

Furthermore, the arbitrator ordered the insurer to pay a $6,000 special award because it unreasonably delayed the payment of attendant care and housekeeping benefits and unreasonably denied non-earner benefits.

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

A previous arbitration dealt with her loss of earning capacity (LEC) benefit, during which her counsel agreed to a specific pre-accident earning capacity (PEC) amount.

Three years later, the applicant sought to challenge the PEC calculation again following a mandatory review under section 33 of the Schedule.

The insurer raised preliminary issues of limitation periods, issue estoppel, and jurisdiction.

The arbitrator found that while the limitation period had not expired and the Commission had jurisdiction, the applicant was bound by her counsel's previous agreement on the PEC amount.

The arbitrator held that section 33 does not automatically reopen the PEC calculation and that the applicant was estopped from relitigating the issue.

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

The insurer disputed the claim and requested that the applicant attend psychiatric and neurological insurer examinations (IEs).

The applicant refused to attend, arguing the request was a last-minute tactic.

On a preliminary issue hearing, the arbitrator found that the insurer's request was reasonably necessary because the applicant's initial neuropsychological assessment was based on incomplete pre-accident records, which the applicant had refused to provide until shortly before the hearing.

The arbitrator ordered that the applicant is precluded from proceeding to arbitration until he makes himself reasonably available for the requested IEs.

The appellant was injured in a motor vehicle accident and sought statutory accident benefits for treatment to her right knee, housekeeping expenses, and a special award.

The insurer cross-appealed the arbitrator's finding that the knee injury was caused by the accident.

The Director's Delegate dismissed the insurer's cross-appeal, finding sufficient medical evidence to support causation.

The Director's Delegate also dismissed the appellant's appeal, upholding the arbitrator's rulings that the appellant was limited to recovering expenses described in the initial treatment plans, that she failed to prove entitlement to housekeeping expenses, and that the insurer's denial of benefits was not unreasonable so as to warrant a special award.