OFSCDRS 2002

The applicants' claims for statutory accident benefits were brought by a treatment provider and paralegal without proper authorization from the applicants.

The insurer sought expenses and an assessment, alleging abuse of process.

The arbitrator allowed Mr. Gurevich to withdraw his application without personal liability for expenses, finding that the treatment provider and representatives were the directing minds behind the abuse of process.

Ms. Gurevich's application was dismissed for failure to produce a required authorization.

The insurer was granted the option to claim its expenses from the treatment provider and representatives.

The appellant appealed an arbitration order dismissing her claim for the cost of five medical assessments and refusing a special award against the insurer.

The appellant argued the arbitrator erred by allowing the insurer to raise new grounds for denying benefits at the hearing and by making factual errors.

The Director of Arbitrations dismissed the appeal, finding no error of law or breach of natural justice in allowing the insurer to alter its position, as the overriding factor is fairness and the appellant was not unduly prejudiced.

The Director also upheld the arbitrator's factual findings that the assessments were not reasonable expenses under section 24 of the SABS.

The appellant was ordered to pay $2,000 in appeal expenses.

The applicant sought an assessment of his arbitration expenses following a decision that denied his claim for income replacement benefits but allowed his claim for housekeeping expenses.

The applicant claimed $35,691.16 in legal fees and disbursements.

The arbitrator reduced the hourly rate and preparation time claimed by the applicant's counsel, finding them excessive given the complexity of the case and counsel's conduct.

The arbitrator also reduced certain disbursements, including the cost of an accountant's report and travel expenses.

The insurer was ordered to pay the applicant $18,424.74 in arbitration expenses.

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

The insurer argued that the applicant's claims for income replacement benefits and supplementary medical benefits were time-barred under section 281(5) of the Insurance Act and section 72 of the Statutory Accident Benefits Schedule.

The arbitrator found that the insurer's initial communications did not constitute a clear and unequivocal refusal of a crystallized claim for income replacement benefits.

The arbitrator also held that an insurer cannot issue a blanket refusal in advance for future supplementary medical benefits.

The applicant was permitted to proceed to arbitration for her income replacement benefits claim and for supplementary medical benefits claimed after March 20, 1998.

Following an arbitration where the insured was unsuccessful in claiming a medical benefit, the insurer sought its expenses.

The arbitrator considered the criteria under the Dispute Resolution Practice Code, including the insurer's offer to settle and the insured's lack of success and credibility issues.

Balancing these factors with the need to maintain accessibility to the dispute resolution system for individuals of modest means, the arbitrator awarded the insurer one-third of its assessed expenses, totaling $3,179.55 plus GST.

The respondent, a Colorado resident, was injured in a motor vehicle accident in New York State while a passenger in an Ontario-insured vehicle.

The appellant insurer paid New York first-party benefits but denied Ontario statutory accident benefits.

The arbitrator ordered the appellant to pay Ontario benefits, finding the respondent was an 'insured person' under the policy's expanded definition.

On appeal, the Director of Arbitrations rescinded the order, holding that the expanded definition in clause (g) of the policy was intended to fill a specific gap in the priority rules for accidents involving other vehicles, and did not extend coverage to non-resident occupants injured outside Ontario.

An application for arbitration for statutory accident benefits was filed in the name of a minor by an agent.

The insurer brought a motion to dismiss the application on the basis that the minor lacked the capacity to authorize the proceeding.

The arbitrator found that the retainer agreement was void due to the applicant's minority and that the agent, having acted without valid authorization, was the actual applicant.

The arbitration was dismissed, and the agent was given an opportunity to respond to the insurer's claim for expenses.

Following a preliminary decision dismissing the applicant's claims for caregiver, housekeeping, and medical and rehabilitation benefits as time-barred, the parties sought expenses for the preliminary hearing.

However, the parties subsequently advised that certain medical rehabilitation expenses were not time-barred and would proceed to arbitration.

The arbitrator deferred the issue of expenses for the preliminary hearing to the arbitrator hearing the remaining outstanding issues.

The applicants, husband and wife, were injured in a motor vehicle accident and filed separate applications for arbitration against their insurer.

The Commission's case administrator improperly combined the applications without authority or notice.

At the pre-hearing discussion, the arbitrator ruled the administrative combination invalid but ordered the matters to be heard at the same time due to overlapping issues and identical witnesses, while remaining registered as separate proceedings pending further submissions on combining them.

Following a settlement of disputed claims for statutory accident benefits, the applicant sought an assessment of his legal expenses.

The insurer agreed the applicant was entitled to expenses but disputed the amount, specifically the hourly rate of the senior counsel, the rate and hours of the law clerk, and certain disbursements including accountant's reports.

The arbitrator allowed the senior counsel's rate of $150 per hour, the law clerk's rate of $45 per hour, and most of the disbursements, awarding a total of $19,449.35 in fees and disbursements.

The applicants, husband and wife, were injured in a motor vehicle accident and filed separate applications for arbitration regarding statutory accident benefits.

A Commission case administrator purported to combine the applications without following the notice and consent requirements of the Dispute Resolution Practice Code and the Statutory Powers Procedure Act.

At a pre-hearing discussion, the arbitrator found the administrative combination invalid but, exercising adjudicative discretion and with the consent of both parties, formally ordered the proceedings combined to avoid inconsistent results, save costs, and promote efficiency given the overlapping facts and witnesses.

The applicant was involved in three motor vehicle accidents in 1995 and 1996.

He sought income replacement benefits and loss of earning capacity benefits (LECB) for the second and third accidents, arguing he was entitled to multiple LECB offers.

The arbitrator found that the applicant was substantially disabled by the first accident and that the subsequent accidents did not materially contribute to his disability.

The arbitrator also interpreted the Statutory Accident Benefits Schedule to mean that an insured is only entitled to one LECB offer for a qualifying disability, even if multiple accidents contributed to it.

The applicant's claims for additional benefits and a special award were dismissed, but he was awarded his arbitration expenses due to the novelty of the legal issues raised.

The applicant applied for arbitration regarding her entitlement to loss of earning capacity benefits following a motor vehicle accident.

The insurer raised a preliminary issue, arguing the applicant was precluded from proceeding to arbitration because she refused to attend an updated insurer's medical examination.

The arbitrator found the insurer's request for a single updated examination by a doctor who had previously examined the applicant was reasonable and not overly onerous.

The applicant was ordered to attend the examination before proceeding to arbitration.

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

The parties disputed the calculation of income replacement benefits (IRBs) and loss of earning capacity benefits (LECBs).

The arbitrator held that the employer's CPP contributions should not be included in the applicant's income for calculating IRBs.

The arbitrator also found that the insurer was entitled to assess the applicant's LECBs based on the Residual Earning Capacity Designated Assessment Centre (REC DAC) report, as it carries more weight than independent medical reports at this stage.

Finally, the arbitrator ruled that the insurer could not deduct prior disability payments made by another insurer, as the settlement agreement only permitted the deduction of the new settlement funds.

The applicant sought to withdraw her application for arbitration regarding statutory accident benefits at the pre-hearing stage, intending to pursue the claim in an ongoing court action.

The insurer agreed to the withdrawal but sought an award for its assessment fee and arbitration expenses, arguing the application was an abuse of process due to venue-splitting.

The arbitrator found that the applicant's conduct was not an abuse of process, as the application was filed before case law strongly discouraged venue-splitting.

The insurer's request for costs and assessment fees was dismissed, and the applicant was permitted to withdraw her application unconditionally.

The applicant was injured in a motor vehicle accident and claimed income replacement benefits (IRBs) and rehabilitation expenses for university studies.

The arbitrator found that the applicant suffered psychological impairments, including post-traumatic stress disorder and depression, that rendered her substantially unable to perform her pre-accident clerical duties for the first 104 weeks post-accident.

However, she failed to prove a complete inability to engage in any suitable employment after the 104-week mark.

The claim for university tuition as a rehabilitation expense was denied because it was not demonstrated to be a reasonable and necessary measure to reintegrate her into the labour market.

Finally, the arbitrator ruled that the 4 percent vacation pay the applicant received on each paycheque must be included in her income from employment for the purpose of calculating her IRB quantum.

The applicant was injured in a motor vehicle accident and sought income replacement benefits for work performed at an equine centre in exchange for boarding her horses.

The insurer denied the claim, arguing the arrangement was not employment or, alternatively, was self-employment.

The arbitrator found that the applicant was an employee, not self-employed, and that her income included the value of the payment in kind (horse boarding).

The applicant was awarded $1,639.90 in income replacement benefits.

Claims for a special award and for a frivolous arbitration penalty were dismissed.

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

The insurer terminated weekly income replacement benefits, and the insured applied for arbitration.

At a pre-hearing discussion, the insurer sought production of the insured's entire long-term disability file from a collateral benefits carrier.

The arbitrator dismissed the request, finding that the documents lacked relevance because the disability tests under the Statutory Accident Benefits Schedule and the collateral carrier's policy were different.

Furthermore, the arbitrator held that compelling production would prejudice the dispute resolution process by potentially allowing a doubling up of medical reports and circumventing the lack of pre-hearing discovery in the arbitration process.

The applicant was injured in two motor vehicle accidents and claimed various statutory accident benefits from her insurer.

The insurer argued she had signed a full and final release for her income replacement benefits, which also barred her claim for loss of earning capacity benefits (LECBs).

The arbitrator found the release only applied to income replacement benefits and that the applicant was entitled to an offer for LECBs because she was substantially unable to perform the essential tasks of her pre-accident employment at the 104-week mark.

The arbitrator also awarded supplementary medical expenses, housekeeping and attendant care benefits, and a special award against the insurer for unreasonably withholding certain benefits.

The applicant claimed statutory accident benefits from the transit insurer following a bus accident.

The insurer denied the claim, arguing the applicant was covered under her estranged husband's policy with another insurer and had wilfully misrepresented her coverage status on her application.

The arbitrator found that the applicant, through her legal representative, intentionally or recklessly failed to disclose her spouse's insurance policy on her application.

As a result, the applicant was precluded from receiving benefits from the transit insurer due to wilful misrepresentation under subsection 48(1) of the Statutory Accident Benefits Schedule.

The application was dismissed with no costs awarded.