OFSCDRS 2003

The applicant was injured in a motor vehicle accident and elected to receive caregiver benefits after meeting with the insurer's adjuster.

She later sought to change her election to income replacement benefits, arguing the election was invalid because the adjuster failed to fully inform her of the consequences.

The arbitrator found that the insurer failed to comply with its obligation under section 32(2)(d) of the Statutory Accident Benefits Schedule to provide complete information, specifically that the benefit paying the most money might not pay for the longest period.

The election was deemed invalid, and the applicant was permitted to claim income replacement benefits.

The applicant was injured in a motor vehicle accident and received income replacement benefits for 104 weeks.

The insurer subsequently offered a loss of earning capacity benefit (LECB) of zero, arguing the applicant had a residual earning capacity as a retail trade manager.

The applicant disputed this, citing severe psychological impairments including PTSD, depression, and panic attacks that prevented sustained employment.

The arbitrator found that the Designated Assessment Centre failed to account for the applicant's psychological limitations when suggesting vocational alternatives.

Accepting the evidence of the applicant's treating psychologist, the arbitrator concluded the applicant's residual earning capacity was zero and awarded an LECB of $375.36 per week, without deduction for unsuccessful post-accident work attempts.

Following earlier decisions regarding statutory accident benefits, the parties disputed the applicant's entitlement to interest on reinstated income replacement benefits and the quantum of hearing expenses.

The insurer argued the interest claim was res judicata because a special award had already been granted.

The arbitrator held that the applicant was entitled to interest under section 46 of the Schedule, finding the special award did not preclude a separate claim for interest.

The arbitrator also assessed the applicant's bill of costs, allowing deductions for premature motion expenses while denying other requested reductions, and remained seized of any remaining disputes.

The applicant was injured in a motor vehicle accident and sought payment for the costs of various medical assessments and treatment plans from a rehabilitation centre under section 24 of the Statutory Accident Benefits Schedule.

The insurer denied the claims.

The arbitrator found that the applicant had withdrawn her treatment plans, breaking the link between the assessments and her claim for accident benefits.

Furthermore, the arbitrator found the assessments to be unreasonable, duplicative, or prepared by individuals not qualified as health professionals.

The claim for examination expenses was dismissed in its entirety.

The applicant, a plumber, was injured in a motor vehicle accident and sought income replacement benefits (IRBs) after the insurer terminated them.

The arbitrator found that the accident aggravated the applicant's pre-existing back condition, causing a substantial inability to perform the essential tasks of his job, particularly driving long distances and working in awkward positions.

The applicant was awarded IRBs for the disputed period, along with interest.

Claims for medical assessment expenses and an MRI were dismissed as they were either arbitration expenses or not properly claimed under the Schedule.

The claim for a special award was also dismissed, as the insurer had a justifiable basis for terminating benefits based on a DAC report.

The applicant claimed she was injured in a bus rollover accident in New York and sought income replacement benefits, medical expenses, and clothing expenses from her insurer.

The insurer denied the benefits.

At arbitration, the arbitrator found that while an accident likely occurred, the medical evidence did not establish that the applicant suffered a substantial inability to perform the essential tasks of her pre-accident employment as a chambermaid.

Claims for taxi, motel, and clothing expenses were also dismissed for lack of evidence.

The insurer's late argument that the applicant was disentitled for failing to provide information was rejected.

The insurer was ordered to pay 70% of the applicant's arbitration expenses due to the applicant advancing legitimate claims, reduced because of late production of her arbitration brief.

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

She claimed she was unable to perform her work as an electrolysist and had to hire a replacement worker.

The arbitrator found the applicant's financial records unreliable and unsupported by source documentation.

The arbitrator concluded that the applicant continued to work after the accident at or above her pre-accident level and did not hire a replacement worker.

The claims for income replacement benefits, housekeeping expenses, and a special award were dismissed.

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

The insurer had terminated her benefits, and the applicant argued she was entitled to interim benefits based solely on financial need and the insurer's defective termination notice.

The arbitrator dismissed the motion, holding that the test for interim benefits requires both financial urgency and a prima facie case for entitlement based on health.

Because the applicant elected to proceed without providing medical evidence, she failed to establish a prima facie case.

The arbitrator also rejected the argument that a defective termination notice created a positive obligation to pay benefits on the merits.

The appellant appealed an arbitration order, alleging that the Arbitrator was biased, spoke to her representative in an antagonistic manner, and ignored evidence and submissions.

The appellant failed to order a transcript of the hearing despite being warned that the allegations of bias needed to be proven with evidence from the record.

The Director's Delegate dismissed the appeal, finding that without a transcript, the appellant could not substantiate her claims regarding the Arbitrator's conduct or evidentiary rulings.

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

The applicants were injured in a motor vehicle accident and applied for statutory accident benefits.

The insurer denied certain treatment plans, and the applicants applied for arbitration.

At a pre-hearing, the insurer requested that several additional, unmediated treatment plans be added to the arbitration.

The arbitrator held that while mediated treatment plans would be included, the unmediated treatment plans from October 2002 lacked a clear temporal relationship to the earlier plans and would not be added at this time.

The appellant, who was injured in a motor vehicle accident, appealed an arbitration decision denying his claim for a special award due to delayed income replacement benefits (IRBs) and medication expense payments.

The appellant argued the arbitrator erred in interpreting the Statutory Accident Benefits Schedule (SABS) to mean that mailing a cheque within the benefit period satisfied the payment requirement.

The Director's Delegate upheld the arbitrator's interpretation, finding that the SABS deems the date of mailing as the date of payment.

The Delegate also found no error in the arbitrator's refusal to grant a special award, noting the lack of precise evidence regarding the amount of delayed medication benefits and the arbitrator's appropriate exercise of discretion regarding the IRBs.

The appeal was dismissed.

The insurer brought a motion to stay the applicants' arbitration proceedings for statutory accident benefits until all outstanding, unmediated treatment plans were mediated and combined into a single proceeding.

The insurer also sought to exclude the applicants' representative.

The arbitrator granted a stay of the arbitrations pending the resumption of a pre-hearing to prevent a potential abuse of process and multiplicity of proceedings.

The requests to immediately add the unmediated plans and to exclude the representative were dismissed as premature and unwarranted, respectively.

The insurer was awarded $300 in expenses.

The applicant claimed statutory accident benefits following a motor vehicle accident and applied for arbitration after mediation failed.

The applicant and her representatives failed to attend the scheduled arbitration hearing, failed to comply with undertakings, and failed to serve documents.

The arbitrator dismissed the application as abandoned.

Finding that the applicant commenced the arbitration with no intention of proceeding, which constituted an abuse of process designed to pressure the insurer into settlement, the arbitrator ordered the applicant to pay the insurer $3,000 under section 282(11.2) of the Insurance Act, plus the insurer's expenses thrown away.

The applicant was injured in a motor vehicle accident and received loss of earning capacity benefits.

The insurer reduced these benefits based on a Designated Assessment Centre report concluding the applicant could work as a part-time telemarketer.

The arbitrator found the assessment seriously flawed, as it failed to consider the applicant's chronic pain, medications, commute, and vocational characteristics.

The arbitrator determined the applicant's residual earning capacity was zero, ordered the insurer to repay the deducted amounts, and granted a special award of $6,000 due to the insurer's unreasonable reliance on the flawed report.

The appellant was injured in a motor vehicle accident and received income replacement benefits for two years until the insurer terminated them, arguing she did not meet the 'any occupation' test.

At arbitration, the Arbitrator ordered benefits reinstated but only until September 2000, inferring from a psychiatrist's report that the appellant could perform some work.

On appeal, the Director's Delegate found the Arbitrator erred in law by drawing an inference that was not supported by the evidence, as the psychiatrist's report did not recommend a work trial but merely suggested one to prove his unqualified opinion that she was completely disabled.

The appeal was allowed and the issue of entitlement to benefits was remitted to a new arbitration hearing.

Following a preliminary issue hearing where the insurer successfully argued that the applicant was bound by a prior agreement regarding her pre-accident earning capacity, both parties sought their expenses.

The arbitrator found that the insurer was the successful party and was entitled to expenses.

The insurer argued that the applicant's law firm should personally pay the expenses due to an alleged abuse of process and conflict of interest.

The arbitrator held that while the tribunal has jurisdiction under the Statutory Powers Procedure Act to sanction non-parties for egregious abuse of process, the evidence did not establish gross negligence or dereliction of duty by the law firm.

The insurer's expenses were fixed at $500, payable by the applicant, due to the insurer submitting an outrageous and unsubstantiated bill of costs on the eve of the hearing.

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

The parties reached an oral settlement agreement, and the insurer forwarded the settlement documents and a release.

The applicant reconsidered and did not sign the release.

The insurer argued the claim was settled on a full and final basis.

The arbitrator found that the settlement was enforceable because the insurer complied with the Settlement Regulation by forwarding the disclosure and release, and the applicant failed to deliver a written notice of rescission within the two-day cooling-off period.

The applicant was precluded from proceeding to arbitration.

The insurer requested a stay of the arbitration hearing or an adjournment to compel the applicant to attend two insurer medical examinations (IMEs) scheduled shortly before the hearing.

The arbitrator found that the insurer failed to provide reasonable notice or consult with the applicant regarding the scheduling of the IMEs, as required by section 42 of the Statutory Accident Benefits Schedule.

The arbitrator concluded the IMEs were sought to bolster the insurer's case for arbitration rather than to adjust the claim, and no extraordinary circumstances justified the late requests.

The motion was dismissed and the hearing was ordered to proceed as scheduled.

The applicant and her counsel failed to attend a scheduled resumption of a pre-hearing discussion regarding statutory accident benefits.

The applicant's counsel had decided attendance was unnecessary but failed to notify the Commission or the insurer's counsel, resulting in wasted preparation time.

The arbitrator found this conduct tended to prolong, obstruct, or hinder the proceeding under s. 12(2) of O. Reg. 664.

The applicant was ordered to pay $300 to the insurer forthwith for costs thrown away.

The applicant was injured in a motor vehicle accident but did not notify his insurer of his intention to claim statutory accident benefits until nine months later.

The insurer refused to pay for medical expenses on the basis of late notice.

The applicant argued he had an innate fear of medical professionals and hoped his injuries would subside.

The arbitrator found the applicant's explanation lacked credibility due to inconsistencies in the evidence and his failure to attend the hearing.

The arbitrator concluded the applicant did not have a reasonable explanation for the delay and is precluded from proceeding to arbitration.