OFSCDRS 2002

The applicant sought expenses following a successful arbitration for statutory accident benefits.

The insurer disputed the hourly rate, the total hours claimed by the applicant's counsel, and certain disbursements.

The arbitrator awarded the maximum hourly rate of $150 for the applicant's experienced counsel, finding the case complex and vigorously pursued.

The arbitrator allowed most of the claimed hours and disbursements, resulting in a total expense award of $36,098.46, less amounts already paid.

The applicant, who was injured in a motor vehicle accident, sought an order for interim benefits pending her arbitration hearing.

The insurer had reduced her weekly benefits to recover an alleged overpayment.

The arbitrator dismissed the application for interim benefits, finding that the applicant failed to establish that her need was urgent and could not await a full hearing.

The evidence of financial hardship provided in her affidavit was deemed too vague and incomplete to justify an interim order.

The applicant sought income replacement benefits following a motor vehicle accident.

The applicant failed to attend the arbitration hearing, and his counsel was granted leave to withdraw.

Relying on the insurer's medical evidence that the applicant's ongoing impairment was related to a prior workplace accident, the arbitrator dismissed the claim for benefits.

The arbitrator found the applicant's failure to attend or maintain contact with his counsel constituted an abuse of process, ordering him to pay $3,000 under subsection 282(11.2) and $1,000 in expenses under subsection 282(11) of the Insurance Act.

The applicants, who were injured in a motor vehicle accident, sought to have their two separate applications for arbitration combined pursuant to Rule 30 of the Dispute Resolution Practice Code.

The insurer supported the combination to save on assessment expenses.

The arbitrator declined to combine the applications, finding that the legislative scheme contemplates a user-pay system for dispute resolution, and combining substantive, distinct claims would unfairly shift the financial burden to the general market share assessment rather than the specific users of the system.

The applicant was injured in a motor vehicle accident and received a weekly income replacement benefit (IRB) of $209.49.

Upon turning 65, the insurer reduced her weekly IRB to $17.64 pursuant to the formula in section 9 of the Statutory Accident Benefits Schedule.

The applicant argued that she was entitled to a minimum weekly IRB of $185 under section 6(1)(b) of the Schedule.

The arbitrator held that section 9 provides a complete code for calculating IRBs after age 65 and replaces the formula in section 6.

The applicant's weekly IRB after age 65 was determined to be $17.64.

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

The insurer terminated weekly income benefits after 156 weeks.

The applicant sought ongoing benefits, claiming she was continuously prevented from working as a dressmaker due to chronic pain and fibromyalgia.

The arbitrator dismissed the claim for ongoing benefits, relying heavily on surveillance evidence that contradicted the applicant's reported functional limitations.

However, the arbitrator found that collateral benefits received by the applicant from private disability policies were not deductible from her pre-156 week income benefits, ordering the insurer to pay the shortfall with interest.

The insurer appealed an arbitration decision that ordered it to pay a maximum special award of 50 per cent ($61,829.52) for unreasonably withholding or delaying the payment of income replacement benefits.

The insurer argued that the arbitrator failed to consider the insured's failure to mitigate, the insurer's payment of the claim prior to the hearing, and that no benefits were owing at the time of the award.

The Director of Arbitrations dismissed the appeal, finding no error of law in the arbitrator's assessment of the evidence or her conclusion that the insurer's conduct warranted the maximum special award.

The appellant was injured in a motor vehicle accident and initially awarded ongoing income replacement benefits.

Years later, the respondent insurer applied to revoke the benefits, arguing a material change in circumstances.

The arbitrator found that the appellant's medical condition had improved and that her extensive involvement in a highly successful gospel choir demonstrated a capacity for suitable employment, terminating her benefits.

On appeal, the Director's Delegate upheld the arbitrator's decision, finding no error of law in the determination that a material change had occurred and that the appellant was no longer continuously prevented from engaging in suitable employment.

The applicant sought statutory accident benefits, including caregiver benefits and medical expenses, alleging that a 1994 motor vehicle accident caused a disc herniation in 1996.

The arbitrator found that the applicant's evidence regarding the onset of her disability was unsupported by contemporary medical documentation, which indicated the disability began at the time of the herniation, more than two years after the accident.

Furthermore, expert medical evidence failed to establish a causal link between the 1994 accident and the 1996 disc herniation.

All claims for benefits, expenses, and a special award were denied.

The applicant was injured in a rear-end motor vehicle accident and sought payment for 99 active rehabilitation treatment sessions and four treatment plans.

The insurer denied the treatment plans, arguing the duration and cost were excessive.

The arbitrator found that the applicant required supervised active rehabilitation to return to his pre-accident heavy labour job and that the duration of the program was reasonable.

However, the arbitrator reduced the hourly rate from the claimed $150 to $60 per session, noting the treatment was provided in a group setting rather than one-on-one.

The arbitrator also awarded interest on overdue payments and a $1,000 special award, finding the insurer unreasonably withheld payments by unilaterally reducing the rate for approved treatment without a valid basis.

The parties cross-appealed an arbitrator's decision regarding the insured's entitlement to loss of earning capacity benefits (LECBs) and rehabilitation expenses following a motor vehicle accident.

The Director's Delegate upheld the arbitrator's calculation of the self-employed insured's pre-accident earning capacity (PEC), finding no error of law in the factual assessment.

However, the Delegate allowed the insurer's appeal regarding residual earning capacity (REC), holding that the arbitrator erred in law by shifting the onus to the insurer to prove the availability of suitable alternative employment.

The REC was reassessed at $145.30 per week, reducing the weekly LECB to $358.10.

The insured's appeal for the cost of labour to complete his home construction was dismissed as it did not serve a rehabilitative purpose under section 40 of the SABS.

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

The arbitrator found that the applicant failed to prove he was a self-employed musician prior to the accident, dismissing his claim for income replacement benefits.

The arbitrator also found that while the applicant suffered from chronic pain and depression, he did not suffer a substantial inability to perform his essential tasks, dismissing his claim for non-earner benefits.

The insurer was awarded its expenses for the arbitration.

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

The insurer refused to pay benefits on the basis that the applicant provided late notice of his intention to claim benefits.

The applicant argued that his medical condition and reliance on counsel provided a reasonable explanation for the delay.

The arbitrator found that while the medical explanation was reasonable up until the time the applicant retained counsel, the simple reliance on counsel thereafter did not constitute a reasonable explanation.

The applicant was therefore precluded from proceeding to arbitration.

The respondent's counsel filed an application for arbitration without knowing his client had died a few days earlier.

The insurer argued the application was a nullity.

The arbitrator allowed the application to proceed, relying on the doctrine of relation back and Rule 9.03(3) of the Rules of Civil Procedure.

On appeal, the Director of Arbitrations held that neither the doctrine of relation back nor the Rules of Civil Procedure applied to the arbitration.

However, the Director concluded that the Dispute Resolution Practice Code provided sufficient authority to correct the defect and allowed the arbitration to proceed, provided the estate trustee confirmed his involvement.

The insurer requested a correction to a previous arbitration order regarding the calculation of Loss of Earning Capacity (LEC) benefits.

The arbitrator found jurisdiction under the Statutory Powers and Procedure Act and the Dispute Resolution Practice Code to correct the technical calculation error, which had failed to deduct UI, CPP, and income tax from the pre-accident income.

The LEC benefits were recalculated and reduced accordingly.

The arbitrator also determined that the insured was entitled to her expenses of the arbitration process, as she was largely successful in establishing her entitlement to the LEC benefit and the insurer had not made an offer to settle.

The applicants applied for statutory accident benefits following a motor vehicle accident.

The insurer requested that the applicants attend insurer examinations and produce certain documents, which the applicants refused.

On a preliminary issue, the arbitrator found that the insurer had a prima facie case for the requested examinations and that the applicants failed to make themselves reasonably available.

The arbitration hearings were adjourned until the applicants attend the examinations.

No production orders were made at this time, pending further submissions from the parties.

The applicant was injured in two motor vehicle accidents in 1995 and sought ongoing income replacement benefits (IRBs) and rehabilitation benefits from the insurer.

The arbitrator found that the applicant had a legitimate contract of employment as a truck driver trainee prior to the second accident and was substantially unable to perform the essential tasks of that employment due to injuries sustained in the accident, specifically heterotopic bone formation affecting his ability to sit for prolonged periods.

The applicant was awarded IRBs based on the truck driving contract, as well as funding for a vocational assessment at Goodwill Industries and case management services.

The applicant's claim for a higher IRB rate based on his pre-accident work as a taxi driver was dismissed due to a lack of reliable income evidence.

The applicant claimed statutory accident benefits following an alleged incident on a TTC bus.

The insurer denied the claim on the basis that the incident actually occurred on a subway train, which does not meet the definition of an 'automobile' under the Statutory Accident Benefits Schedule.

At arbitration, the arbitrator found that the applicant failed to prove on a balance of probabilities that the incident occurred on a bus, relying on contemporaneous records indicating it occurred on a subway.

The arbitrator also found insufficient medical evidence of an impairment.

The application for benefits was dismissed.

The insurer's request for an award for a frivolous application was denied, but the applicant was ordered to pay half of the insurer's arbitration expenses due to his conduct during the proceeding.

The applicant, a 69-year-old woman, was injured when the city bus she was riding stopped suddenly.

She applied for statutory accident benefits, but the insurer terminated medical benefits and refused to pay for housekeeping.

The arbitrator found that the applicant suffered physical and psychological impairments as a result of the accident, aggravating pre-existing conditions.

The arbitrator ordered the insurer to pay for physiotherapy, psychological treatment, medical assessments, and housekeeping expenses.

The insurer's argument that the applicant was disentitled to benefits for failing to attend a DAC assessment was rejected due to defective notice.

The applicant was awarded her arbitration expenses.

The applicants sought statutory accident benefits following a motor vehicle accident, claiming entitlement to physiotherapy, psychological counselling, housekeeping, and caregiver benefits.

The insurer disputed the claims, arguing that three of the applicants were not in the vehicle and that the claimed benefits were not reasonable or necessary.

The arbitrator found that all applicants were involved in the accident but dismissed all claims for benefits, finding the evidence of disability and need for treatment unreliable or exaggerated.

The arbitrator ordered each applicant to pay $500 towards the insurer's arbitration expenses due to the incompetent and obstructive conduct of their agent.