OFSCDRS 2003

The insurer brought a motion for an order compelling the applicant to produce medical and financial documents, and to add the applicant's entitlement to ongoing income replacement benefits (IRBs) as an issue in the arbitration.

The applicant agreed to provide consents for the release of the requested medical documentation.

The arbitrator found that it was premature to add the IRB issue to the arbitration because the parties were still awaiting a Designated Assessment Centre (DAC) report, and it was unclear if there would continue to be a dispute over the IRB payments.

The issue of expenses for the motion was left to the discretion of the hearing arbitrator.

The applicant sought expenses following a successful arbitration claim for income replacement benefits against the insurer.

The arbitrator found the applicant was entitled to his reasonable arbitration expenses due to his success on the major issue and the professional conduct of the hearing.

After reviewing the claimed hourly rates, allowable hours, and disbursements, the arbitrator awarded the applicant $8,954.64 inclusive of GST.

The appellant was injured in a motor vehicle accident while driving uninsured.

He sent a tort letter to the respondent insurer within the required timeframe, but did not explicitly apply for accident benefits until 18 months post-accident.

The arbitrator found that the tort letter did not constitute notice of an intention to apply for accident benefits under s. 32(1) of the SABS-1996.

On appeal, the Director of Arbitrations upheld the decision, confirming that an insurer must be alerted to the fact that the person wants to apply for accident benefits to trigger the insurer's obligation to provide an application package.

The appeal was dismissed.

The applicant sought to vary or revoke previous arbitration orders denying his claim for income replacement benefits and ordering him to pay arbitration expenses.

He argued there were errors in the orders and sought to introduce fresh evidence.

The Director's Delegate dismissed the application, finding that a variation/revocation proceeding under s. 284 of the Insurance Act cannot be used to re-argue an appeal.

Furthermore, the proposed fresh evidence did not meet the Palmer test, as it could have been adduced at the original hearing and would not have affected the outcome.

The applicant was ordered to pay $500 in expenses.

The Applicant sought to recover GST on disbursements for medical reports as part of her hearing expenses.

The Insurer argued that the medical reports were GST-exempt.

The Arbitrator found that while the reports may be exempt when billed to the lawyer, CCRA policy requires the lawyer to charge GST when billing the client, making the GST recoverable.

The Insurer also argued that the disbursements should be reduced because they were partially recovered in a related tort settlement.

The Arbitrator held he had no jurisdiction to alter his previous costs order based on the subsequent tort settlement.

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

In a preliminary decision during the arbitration hearing, the arbitrator determined that the period of entitlement to IRBs before him included the post-104-week period.

The arbitrator also ruled that the appropriate disability tests were those set out in subsections 5(1) and 5(2)(b) of the Schedule for the pre- and post-104-week periods, respectively.

Finally, the arbitrator allowed the insurer to add the issue of repayment of IRBs to the proceeding based on alleged wilful misrepresentation.

The applicant suffered severe burns when gasoline spilled from his taxi's gas tank during repairs at a garage and ignited.

The insurer denied statutory accident benefits, arguing the fire was an independent intervening act that broke the chain of causation from the vehicle's repair.

The arbitrator found that the injuries were directly caused by the use or operation of the vehicle, as the repair process set in motion an unbroken chain of events leading to the fire.

The presence of fire hazards in a garage was considered a normal incident of the risk created by repairing a vehicle.

The applicant was deemed to have been injured in an 'accident' under the Schedule and was awarded expenses for the preliminary hearing.

The applicant was a passenger on a public transit bus.

She alleged that as she was exiting the bus, the doors closed on her jacket and purse, and the bus moved, causing her injury.

She applied for statutory accident benefits.

The insurer denied the benefits and raised two preliminary issues: whether an "accident" occurred within the meaning of the Statutory Accident Benefits Schedule, and whether the applicant was precluded from proceeding to arbitration for failing to attend insurer's examinations.

The arbitrator found that the applicant's jacket and purse were caught in the doors, constituting an "accident".

Furthermore, the arbitrator held that the insurer's notice of examinations was defective because it failed to state the specific benefits to which the examinations related, as required by section 42(2) of the Schedule.

Therefore, the insurer could not rely on the notice to preclude the arbitration.

The applicant sought caregiver benefits following a minor motor vehicle accident, claiming physical and psychological impairments substantially disabled her from caring for her young daughter.

The arbitrator dismissed the claim, finding the applicant lacked credibility and failed to provide objective medical evidence of a substantial inability to perform caregiving duties.

Surveillance evidence and inconsistencies in testimony further undermined her claim that she incurred caregiving expenses.

The applicant was ordered to pay the insurer's arbitration expenses due to the unmeritorious nature of the claim.

The applicant sought attendant care benefits following a motor vehicle accident.

After his representative withdrew, the applicant failed to attend the rescheduled pre-hearing and the arbitration hearing.

The arbitrator dismissed the claim for attendant care benefits due to the applicant's non-attendance.

The insurer was awarded $1,000 in expenses because the applicant was aware of the proceedings and the claim was deemed manifestly unfounded in the absence of supporting evidence.

The insurer appealed an arbitration decision awarding the insured caregiver and attendant care benefits, as well as a special award.

The insurer argued the insured had not 'incurred' the expenses because she did not pay the family members who provided the care.

The Director's Delegate upheld the arbitrator's finding that the expenses were incurred, noting the insurer failed to advise the insured she could claim for services provided by family members.

However, the appeal was allowed in part because the arbitrator erred by failing to apply the 104-week statutory limit to the benefits.

The Delegate also affirmed the arbitrator's independent jurisdiction to raise the issue of a special award, finding that adequate notice was provided to the insurer.

The applicant sought expenses following an arbitration decision where he achieved partial success in his claims for statutory accident benefits.

The insurer also claimed its expenses, relying on two written offers to settle that exceeded the applicant's recovery.

The arbitrator awarded the applicant 50% of his allowable arbitration expenses, considering his partial success, the insurer's conduct in delaying pre-hearing discussions, and the statutory objective of speedy dispute resolution.

The insurer's claim for expenses was denied, as the arbitrator declined to follow a strict results-based approach based solely on the offers to settle.

The applicant's total allowable expenses were assessed at $13,010, resulting in an award of $6,505.

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

The insurer terminated benefits after 104 weeks and sought repayment, alleging the applicant misrepresented his pre-accident income.

The arbitrator found the applicant was not completely disabled from working as a self-employed renovator, relying on medical evidence including the applicant's own treating surgeon.

The arbitrator also found the applicant lacked credibility and had falsified his tax returns to inflate his business expenses and hide income.

Consequently, the applicant failed to prove the quantum of his income replacement benefit.

The arbitrator ordered the applicant to repay $33,997.72 to the insurer due to wilful misrepresentation and ordered him to pay the insurer's arbitration expenses.

The applicant was injured in a motor vehicle accident and applied for statutory accident benefits, including income replacement and housekeeping benefits.

The insurer denied the income replacement benefits, arguing she was unemployed at the time of the accident.

The arbitrator found that the applicant's casual part-time work as a bartender constituted employment at the time of the accident, entitling her to income replacement benefits for a closed period of 10 weeks.

Claims for further housekeeping expenses and a special award were dismissed.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for massage therapy and a physiotherapy program.

The insurer denied the claims based on Designated Assessment Centre reports.

The arbitrator found the applicant credible and accepted evidence from her treating physician and physiotherapist that the treatments were reasonable and necessary for pain management and physical rehabilitation.

The insurer was ordered to pay $910 for massage therapy and $1,095 for the physiotherapy program.

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

The insurer brought a preliminary motion arguing the applicant was precluded from proceeding to arbitration because she failed to attend scheduled insurer's examinations and failed to return an OCF-14 form required for a Designated Assessment Centre (DAC) assessment.

The applicant's representative also brought a motion to withdraw due to a breakdown in the relationship and the applicant's failure to provide a required authorization.

The arbitrator allowed the representative to withdraw without conditions.

On the preliminary issue, the arbitrator found that while the insurer's notice for the examinations was deficient, the applicant's failure to provide the OCF-14 constituted non-compliance with section 43(2) of the Schedule.

Consequently, the applicant was precluded from proceeding to mediation and arbitration for the disputed medical benefits.

The applicant sought to withdraw her arbitration regarding statutory accident benefits after a preliminary issue decision found her disentitled to certain income replacement benefits for failing to provide reasonably required information under section 33 of the Schedule.

The insurer objected unless conditions were imposed.

The arbitrator allowed the withdrawal on the condition that the applicant pay the insurer's reasonable expenses for the hearing, pay the assessment fee if she recommences the arbitration, and that interest on outstanding benefits be suspended.

The arbitrator also ordered the applicant to pay the insurer's expenses for the second day of the preliminary hearing because she decided not to testify at the last minute, causing unnecessary expense.

The insurer sought its arbitration expenses and assessment fee after the applicant's claim for statutory accident benefits was dismissed on the basis that no motor vehicle accident occurred.

The arbitrator found that the applicant falsely represented that an accident occurred and knowingly pursued a fraudulent claim, constituting an abuse of process.

The arbitrator awarded the insurer $3,388.50 in arbitration expenses and the $3,000 assessment fee.

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

He initially represented to the insurer that he was unemployed at the time of the accident, allegedly to avoid termination of his WSIB benefits.

He later claimed he was employed and sought income replacement benefits.

The insurer denied the benefits, arguing the Applicant wilfully made a material misrepresentation.

The Arbitrator found that employment status is a fundamental aspect of an application for weekly benefits and is therefore a material fact.

The Arbitrator concluded that the Applicant is precluded from receiving income replacement benefits pursuant to section 48 of the Schedule due to his wilful misrepresentation.

The appellant appealed an Arbitrator's decision dismissing his claim for income replacement benefits following a motor vehicle accident.

The appellant argued the Arbitrator erred in assessing the evidence, admitting surveillance videotapes that post-dated the claim period, and finding that the insured bears the onus of proving ongoing entitlement to benefits after an insurer terminates them.

The Director's Delegate dismissed the appeal, holding that the Arbitrator's credibility findings and reliance on the insurer's medical experts were amply supported by the evidence.

The Delegate further held that the surveillance evidence was properly admitted to assess credibility and that the ultimate burden of proving entitlement to benefits remains on the insured person.