OFSCDRS 2002

The applicant was injured in a motor vehicle accident and received income replacement benefits (IRBs) which were later terminated by the insurer.

In an earlier decision, the arbitrator found that the insurer breached section 37(5) of the Statutory Accident Benefits Schedule by terminating IRBs without initiating the dispute resolution process following a positive Designated Assessment Centre (DAC) finding.

In these supplementary reasons, the arbitrator determined the effect of this breach on the ongoing arbitration.

The arbitrator held that the insurer must comply with the procedure set out in section 37(5), meaning it must commence mediation and a court action, and pay IRBs pending the resolution of the dispute.

Consequently, the arbitration concerning the applicant's entitlement to IRBs was concluded, though it could continue regarding housekeeping benefits and a special award.

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

The insurer terminated income replacement benefits and, over four years later, requested that the applicant undergo a medical examination by an orthopaedic surgeon under section 42 of the Statutory Accident Benefits Schedule.

The applicant refused, arguing the examination was not reasonably necessary.

The arbitrator found that the insurer had already conducted multiple assessments by other specialists, including a neurosurgeon and an occupational medicine physician, none of whom recommended an orthopaedic evaluation.

The insurer failed to establish that the proposed examination was reasonably necessary or that its previous assessments were not meaningful evaluations of the applicant's physical condition.

The insurer's request was denied, and the applicant was awarded the expenses of the preliminary issue hearing.

The applicant was injured in a motor vehicle accident and received statutory accident benefits until the insurer terminated them in 1998 based on a Med/Rehab DAC report.

The applicant applied for mediation in 2000 and subsequently for arbitration.

The insurer raised a preliminary issue arguing the application for arbitration was premature because the applicant had not submitted specific claims for expenses prior to mediation.

The arbitrator held that the insurer's 1998 notice refusing to pay further benefits constituted a "dispute" under section 71 of the SABS, triggering the right to proceed to dispute resolution.

The application was not premature.

The arbitration was adjourned pending a new Med/Rehab DAC assessment, and the applicant was ordered to particularize her claimed expenses.

The Applicant was involved in a motorcycle accident and claimed statutory accident benefits for damaged clothing.

The Insurer offered to pay the full amount but required the damaged articles and a completed application form before releasing the cheque.

The Applicant delayed providing the clothing and forms, leading to a dispute over interest and a special award.

The Arbitrator found that the Applicant was entitled to interest from the date he finally tendered the damaged clothing to the Insurer's adjuster until the date the Insurer paid the principal amount.

The Arbitrator dismissed the claim for a special award, finding the Insurer's conduct was not unreasonable.

The Insurer's request for the return of its arbitration assessment fee was denied, and the Insurer was ordered to pay $250 towards the Applicant's expenses.

The appellant abandoned his appeal before the Financial Services Commission of Ontario after his representative was excluded from the proceeding for obstructive conduct during a bias motion.

The Director's Delegate dismissed the appeal and confirmed the arbitrator's order.

The appellant was ordered to pay the respondent's appeal expenses of $1,507.50 due to the frivolous and vexatious nature of the bias motion and the representative's conduct.

The insured suffered catastrophic injuries in a motor vehicle accident and was placed in a long-term care facility.

A dispute arose over whether her automobile insurer was required to pay her chronic care accommodation co-payments under the SABS-1994.

The arbitrator ordered the insurer to pay the full co-payments and awarded a $10,000 special award.

On appeal, the Director's Delegate varied the order, finding that while the insurer is responsible for the co-payments, the SABS secondary payer rule requires the insured to apply for reasonably available partial or full exemptions under the Health Insurance Act to reduce the amount payable.

The special award was revoked because the insurer's delay was not unreasonable given the insured's failure to pursue these exemptions.

The Delegate also revoked the arbitrator's award for past attendant care and support worker services that were never actually incurred.

The applicant, a minor whose mother was killed in a motor vehicle accident, sought statutory accident benefits from the insurer.

The parties engaged in settlement discussions and purportedly reached an agreement.

The applicant brought a motion to enforce the settlement, seeking an order for the insurer to pay a lump sum.

The insurer argued there was no binding settlement due to a lack of consensus ad idem regarding the scope of the release.

The arbitrator found he had jurisdiction to determine the existence of a settlement but concluded that no binding agreement was reached due to mutual mistake regarding the scope of the claims and the temporal scope of the settlement.

The motion to enforce the settlement was dismissed.

The appellant appealed an arbitrator's decision dismissing his claim for further income replacement benefits following two motor vehicle accidents.

The central issue was whether the appellant's essential tasks as a self-employed construction company owner included heavy physical labour or were limited to administrative and supervisory duties.

The Director's Delegate upheld the arbitrator's finding that the appellant's essential tasks were primarily administrative and supervisory, based on evidence of his pre-accident activities and health.

The Director's Delegate also found no error in the arbitrator's refusal to adjourn the hearing pending a Designated Assessment Centre (DAC) assessment, given the appellant's significant delay in pursuing the issue.

The appeal was dismissed.

In a pre-hearing decision regarding a claim for statutory accident benefits, the insurer sought a remedy for the applicant's repeated failure to comply with undertakings and orders to produce medical and financial records.

The arbitrator declined to dismiss the proceeding but found that the applicant's non-compliance warranted a cost consequence.

The applicant was denied her expenses for the pre-hearing process and ordered to pay the insurer $500 in expenses, payable as an offset against any future award.

The applicant was injured in a motor vehicle accident and received income replacement benefits from her automobile insurer, Coseco, as well as long-term disability benefits from London Life through her employer.

Coseco deducted the London Life benefits from the income replacement benefits.

The applicant disputed this deduction, arguing the matter was not settled at mediation and the deduction was unfair.

The arbitrator found that the London Life policy qualified as an income continuation plan under section 7(1) of the Statutory Accident Benefits Schedule, as it provided income security for loss of wages and was tied to her earnings.

Therefore, Coseco was entitled to deduct the collateral benefits.

Each party was ordered to bear their own costs.

The applicant sought payment for the cost of medical assessments under section 24 of the Statutory Accident Benefits Schedule.

Following a previous decision where the arbitrator postponed issuing a final order pending further submissions, no application to reopen the hearing was received.

As the applicant presented no evidence on entitlement to the cost of examinations, she failed to meet her burden of proof.

The application for arbitration was dismissed.

The applicant applied for statutory accident benefits after she was injured when her car rolled down a parking garage ramp.

She had stepped out of the car to use a key box, leaving the engine running.

When the car began to roll, she chased it and tripped, sustaining injuries.

The insurer denied benefits, arguing the incident was not an 'accident' under the Schedule.

The arbitrator found that the use and operation of the automobile directly caused the impairment, as the applicant's fall was part of an uninterrupted chain of events beginning with the use of the vehicle.

The preliminary issue was resolved in favour of the applicant.

The respondents were injured in a motor vehicle accident in California and claimed statutory accident benefits from the Motor Vehicle Accident Claims Fund.

The Fund denied the claim, arguing it was not responsible for out-of-province accidents, and later challenged the arbitrator's jurisdiction to decide the issue.

The arbitrator ruled she had jurisdiction, and the Fund sought leave to appeal this preliminary order before the remaining issues were decided.

The Director's Delegate denied the motion for leave to appeal, finding that proceeding with the appeal could lead to multiple appeal proceedings and unnecessary delay, and deferred the appeal until the remaining issues, including the existence of a potential insurer, were resolved.

The appellant, who suffered a severe brain injury after being struck by an automobile, appealed an arbitrator's decision limiting her attendant care benefits to the minimum hourly wage for Level II care under the SABS-1994.

The insurer cross-appealed the finding that the appellant qualified for education disability benefits despite having withdrawn from high school prior to the accident.

The Director's Delegate dismissed both the appeal and cross-appeal, finding that the regulation strictly limited Level II attendant care to the minimum wage, and that the appellant's withdrawal from school less than a year before the accident satisfied the criteria for having 'completed her education' under the schedule.

The applicant was injured in a motor vehicle accident and sought payment for chiropractic and rehabilitation treatments from his automobile insurer.

The insurer disputed the necessity and cost of the treatments, and argued that the applicant's extended health insurer was the primary payer.

The arbitrator held that the legal burden of proof lies with the insured to demonstrate what collateral benefits were reasonably available and what balance remains owing by the automobile insurer.

The arbitrator found the treatments were reasonable and necessary, adjusted the allowable costs, and ordered the insurer to pay the outstanding balance of $993.

A special award of $250 was also granted against the insurer for unreasonably delaying payment.

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

The insurer terminated benefits after an insurer medical examination, despite a prior Designated Assessment Centre (DAC) report concluding the applicant remained disabled.

The applicant applied for arbitration, arguing the insurer breached section 37(5) of the Statutory Accident Benefits Schedule by failing to dispute the DAC report through the dispute resolution process and instead relying on a new medical examination to terminate benefits.

The arbitrator found that the insurer did not respect the role of the DAC and improperly attempted to circumvent the dispute resolution process.

The insurer was ordered to pay income replacement benefits pending the resolution of the dispute.

Following an arbitration regarding statutory accident benefits where the applicant had limited success, both parties claimed their expenses of the proceeding.

The arbitrator denied the applicant's claim for expenses and awarded the insurer its reasonable expenses from April 2001 onwards.

The arbitrator noted that the applicant's conduct prolonged the proceeding and that he had rejected reasonable offers to settle.

The insurer was awarded $5,296.00 in expenses, while the applicant was awarded $2,763.96 in interest on previously unpaid amounts.

The appellant appealed an arbitrator's decision dismissing his claim for statutory accident benefits after he and his representative failed to attend the arbitration hearing.

The appellant argued that the issues had been settled prior to the hearing and that he did not receive adequate notice.

The Director's Delegate dismissed the appeal, finding no evidence of an accepted settlement offer and concluding that the appellant received proper notice of the peremptory hearing date.

The appellant was ordered to pay $1,000 in expenses.

Following an arbitration decision that denied the applicant's claims for statutory accident benefits due to pervasive credibility issues, the parties sought their respective expenses of the proceeding.

The arbitrator found no basis to order the applicant to pay the insurer's expenses.

However, balancing the applicant's lack of credibility against the complexity of the case and the principle of facilitating access to the dispute resolution system, the arbitrator awarded the applicant one-third of his arbitration expenses.

The applicant was injured in a motor vehicle accident and sought supplementary medical and rehabilitation benefits.

The insurer rejected the claims and argued that the applicant was time-barred from proceeding to arbitration because she applied outside the two-year limitation period under section 281(5) of the Insurance Act.

Applying the Supreme Court of Canada's decision in Smith v. Co-operators Insurance Company, the arbitrator found that the insurer's notices of refusal did not provide full details of the dispute resolution process as required by section 71 of the Statutory Accident Benefits Schedule.

Consequently, there was no valid refusal, the limitation period never began to run, and the applicant was permitted to proceed to arbitration.