OFSCDRS 2003

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

The insurer terminated his weekly income replacement benefits on October 24, 2000.

The applicant applied for arbitration, seeking ongoing income replacement benefits and a special award.

The arbitrator found that the applicant suffered a substantial inability to perform the essential tasks of his employment for the first 104 weeks, and a complete inability to engage in any suitable employment thereafter due to chronic pain and depression.

The arbitrator also found that the insurer unreasonably withheld the benefits despite having sufficient medical and employment information, and awarded a special award of $40,000 inclusive of interest.

The applicant, an 18-year-old pedestrian, was struck by a bus and sustained injuries.

He applied for statutory accident benefits approximately 11 months after the accident.

The insurer denied the claim on the basis of late application without a reasonable explanation.

On a preliminary issue hearing, the arbitrator found that the applicant had a reasonable explanation for the delay, given his youth, reliance on his mother, and the time taken to identify the correct insurer.

Furthermore, the arbitrator held that the insurer failed to promptly provide the applicant with sufficient information regarding the consequences of failing to comply with the time limits, meaning the time limit to submit the application never began to run.

The applicant was permitted to proceed to arbitration.

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

The insurer terminated benefits and the applicant applied for arbitration.

The insurer raised preliminary issues arguing the applicant was precluded from proceeding to arbitration under s. 50(a) of the Statutory Accident Benefits Schedule for failing to notify the insurer within prescribed time limits, and under s. 50(c) for failing to attend a Designated Assessment Centre (DAC) assessment.

The arbitrator found the insurer did not meet its burden to prove the applicant failed to apply within the time limits, as the insurer's own correspondence acknowledged receipt of the application.

However, the arbitrator found the applicant failed to attend a scheduled DAC assessment without explanation.

Consequently, the applicant was precluded from pursuing his claim for medical and rehabilitation benefits at arbitration, but could proceed on other issues.

The applicant was previously ordered to pay the insurer's expenses after her application for arbitration was dismissed as abandoned.

The insurer submitted a bill of expenses for $7,696.28, which included a $3,000 assessment fee already ordered to be paid and counsel fees billed at twice the permitted legal aid rate.

The arbitrator found the bill of expenses to be non-compliant with the Dispute Resolution Practice Code, lacking supporting evidence, and containing frivolous and vexatious claims.

Rather than requiring further proceedings, the arbitrator fixed the insurer's expenses at $750, representing three hours of hearing time at legal aid rates plus necessary disbursements and preparation time.

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

The insurer denied benefits and raised the preliminary issue of wilful misrepresentation.

The applicant objected to the late service of the insurer's expert reports and argued the insurer failed to provide proper notice of the reasons for denying benefits.

The arbitrator allowed the late expert reports, finding no procedural unfairness or prejudice to the applicant.

The arbitrator also held that the insurer provided sufficient notice of its wilful misrepresentation defence in its Response to the Application for Arbitration, allowing the preliminary issue hearing to proceed.

The appellant was injured in a motor vehicle accident and received income replacement benefits (IRBs) from his automobile insurer.

He later received retroactive long-term disability (LTD) benefits from a collateral insurer.

The automobile insurer sought repayment of the IRBs it had paid, claiming the full amount of the LTD benefits.

The Director of Arbitrations held that under section 47(3) of the Statutory Accident Benefits Schedule, the insurer could only recover overpayments of accident benefits made within 12 months prior to giving notice of the overpayment.

The appeal was allowed in part, limiting the repayment obligation and adjusting the interest payable on overdue benefits.

The applicant was injured while attempting to avoid a collision as a pedestrian and applied for statutory accident benefits from the insurer.

The parties proceeded to arbitration on three preliminary issues.

After hearing evidence on the first preliminary issue, the arbitrator declined to issue a decision immediately, finding it necessary in the interests of fairness and efficiency to reserve the decision until the hearing concluded with respect to all three preliminary issues.

The insurer brought a motion to exclude the evidence and report of the applicant's treating physiatrist, arguing he was no longer a qualified practitioner under the Evidence Act due to the revocation of his medical license for professional misconduct.

The arbitrator dismissed the motion, holding that the Statutory Powers Procedure Act permits the admission of relevant evidence and that the prejudice to the applicant in excluding his long-term treating physician outweighed the insurer's concerns of impropriety.

The arbitrator also admitted transcripts of several witnesses from a previous arbitration hearing on consent.

The applicant was injured in a motor vehicle accident and applied for a caregiver benefit under section 13 of the Statutory Accident Benefits Schedule, claiming she was the primary caregiver for her adult brother who suffers from schizophrenia and resides in a mental health facility.

The arbitrator found that the applicant did not qualify for the benefit because she did not reside with her brother, as required by the Schedule, and because the facility staff, rather than the applicant, provided the primary caregiving services.

The preliminary issue was resolved in favour of the insurer.

The applicant sought statutory accident benefits for housekeeping and home maintenance expenses following a motor vehicle accident.

The applicant failed to attend the arbitration hearing.

The arbitrator proceeded in his absence and dismissed the claim, finding insufficient evidence to establish a substantial inability to perform pre-accident housekeeping duties.

The insurer's request to add claims for its expenses and for a frivolous proceeding was denied due to lack of notice to the applicant.

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

Following an initial arbitration and subsequent appeal that remitted the matter for a new hearing, the insurer sought production of independent medical examinations (IEs) obtained in the applicant's related tort action.

The arbitrator considered the recent Court of Appeal decision in Tanner and the tribunal's approach to importing documents from civil actions.

Finding that the insurer had a compelling reason for not obtaining its own updated medical assessments due to the intervening appeal, the arbitrator ordered the applicant to produce the tort IEs in her possession for the period between the first hearing and the appeal decision.

The applicant sought statutory accident benefits after a tenant mistakenly drove her vehicle into the side of his house.

The impact caused a loud noise and shaking, prompting the applicant to panic and run to check on his children.

While running down the stairs, he tripped and fell, sustaining injuries.

The insurer denied benefits, arguing the injuries were not caused by an 'accident' as defined in the Schedule.

The arbitrator found that the car hitting the house directly caused the applicant's injuries, as the sequence of events was one continuous incident without an intervening act.

The arbitrator concluded the applicant was involved in an accident within the meaning of the Schedule.

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

The insurer terminated these benefits based on a Disability Designated Assessment Centre (DAC) report.

The applicant argued the DAC assessment was flawed and did not comply with the guidelines, seeking reinstatement of benefits.

The arbitrator found that the DAC assessment substantially complied with the guidelines and that the termination was valid under section 37 of the Schedule.

The arbitrator also held that the insurer was entitled to conduct further reasonably necessary medical examinations under section 42 to determine entitlement to post-104 week benefits.

The insurer brought a motion for the production of medical and employment records from several non-parties.

The applicant did not object to the production and had previously attempted to obtain the records.

The arbitrator ordered the non-party doctors to produce their complete charts, finding that reasonable efforts had been made and the doctors had a reasonable opportunity to respond.

However, the arbitrator declined to order the non-party employer to produce employment records, as there was insufficient evidence that the employer had been properly served with the motion record and given an opportunity to respond.

The applicant, who suffered from secondary progressive multiple sclerosis, was injured in a motor vehicle accident when she was knocked to the ground by a reversing truck.

She applied for statutory accident benefits, claiming the accident accelerated her deterioration and caused a complete inability to carry on a normal life.

The arbitrator found that while the accident caused a short-term exacerbation of her symptoms, it did not materially contribute to her long-term impairments or continuously prevent her from engaging in substantially all of her pre-accident activities.

Claims for non-earner benefits and assistive devices were dismissed, but the cost of two assessments was awarded as they were reasonably incurred.

The applicant was injured in a 1996 motor vehicle accident and sought various statutory accident benefits, including supplementary medical benefits for an adjustable bed and physiotherapy, rehabilitation benefits for moving expenses and taxi fares, and housekeeping and home maintenance expenses.

The arbitrator found that the applicant had a significant pre-existing medical and psychological history.

The claims for the bed, physiotherapy, moving expenses, and housekeeping were dismissed, as the arbitrator concluded they were either not reasonably necessary or not causally related to the 1996 accident.

However, the claim for taxi expenses to attend occasional social activities was allowed as a reasonable rehabilitation measure to facilitate social reintegration.

Claims for a special award and arbitration assessment fees were dismissed.

The insurer brought a motion to dismiss the applicant's arbitration for statutory accident benefits due to the applicant's repeated failure to comply with production and cost orders.

The arbitrator declined to dismiss the arbitration, finding that the specific notice prerequisites for dismissal without a hearing under Rule 68 of the Dispute Resolution Practice Code had not been met.

However, to prevent an abuse of process under Rule 65.7, the arbitrator stayed the arbitration pending the applicant's compliance with all previous orders and payment of $500 in costs for the motion.

The applicant claimed statutory accident benefits following an alleged motor vehicle accident.

The insurer denied the claim, alleging the accident was staged and the damage was caused by a blunt object.

The arbitrator found that while an incident involving the two vehicles did occur, the applicant failed to prove he suffered a compensable impairment arising from the accident.

Furthermore, the arbitrator found that the applicant made wilful false statements regarding his medical history and prior accidents, thereby forfeiting his right to recover indemnity under section 233(1)(c) of the Insurance Act.

The application for benefits was dismissed.

The insurer appealed an arbitration decision ordering it to pay income replacement benefits beyond the 104-week mark, a maximum special award, and arbitration expenses.

The Director of Arbitrations upheld the ongoing entitlement to income replacement benefits, finding that the evidence supported the conclusion that the insured suffered a complete inability to engage in suitable employment.

However, the special award was reduced to $5,000 because the insurer's initial reliance on its experts was not unreasonable, and the arbitration expenses were slightly reduced to exclude pre-mediation legal work.

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

When the matter proceeded to an arbitration hearing, the Applicant failed to attend.

The Arbitrator dismissed the application for arbitration due to the Applicant's failure to lead evidence.

The Insurer sought its expenses and a special award for a frivolous or vexatious proceeding.

The Arbitrator ordered the Applicant to pay the Insurer's reasonable expenses of $2,554.89 but declined to order a penalty for a frivolous proceeding because the relevant statutory provision had been repealed and the Insurer failed to provide advance notice of the claim.