OFSCDRS 2004

The applicant, a 74-year-old pedestrian, was struck by a vehicle and sustained injuries including a fractured knee.

He later passed away from unrelated causes.

His Estate sought non-earner and attendant care benefits.

The arbitrator dismissed the claims, finding that the applicant did not suffer a complete inability to carry on a normal life, as he resumed most pre-accident activities after his cast was removed.

The claim for attendant care benefits was also dismissed due to a lack of evidence regarding the services provided, by whom, and for what period, as no Form 1 was submitted.

The applicant was injured while standing in a TTC bus that was struck by a tow truck.

She claimed statutory accident benefits, which the insurer terminated, alleging she was not disabled and had fraudulently claimed benefits while receiving welfare.

The arbitrator found that the accident exacerbated the applicant's pre-existing depression, rendering her substantially unable to perform her essential tasks of caring for her children until October 1994.

The arbitrator dismissed the insurer's claim for repayment, finding insufficient evidence of fraud and concluding that the applicant lacked the mental capacity to form a fraudulent intent at the time the claims were made.

Claims for physical rehabilitation expenses were dismissed.

The insurer requested a preliminary issue hearing to determine whether the insured was precluded from proceeding to arbitration due to her refusal to attend a psychiatric examination scheduled by the insurer.

The arbitrator found that the insurer had ample notice of the insured's psychological symptoms but waited until after the pre-hearing to schedule the examination.

The arbitrator concluded the request was a tactical maneuver to bolster the insurer's case rather than for adjusting purposes.

The insurer's request was deemed unreasonable, and the insured was permitted to proceed to the arbitration hearing.

Following a decision denying the applicant's claim for income replacement benefits, the insurer sought an award of its arbitration expenses, alleging the applicant caused delays and called unnecessary witnesses.

The arbitrator found no evidence of intentional obstruction or neglect by the applicant, noting the insurer raised its successful exclusion defence only a month before the hearing.

The arbitrator concluded that the applicant acted in good faith and ordered each party to bear its own costs.

The applicant, who sustained a severe closed head injury in a motor vehicle accident, brought a motion to add issues to an upcoming arbitration hearing regarding statutory accident benefits.

The proposed additional issues concerned estate management expenses and out-of-pocket travelling expenses for family members.

The arbitrator dismissed the motion, finding that adding the complex estate management issues so close to the hearing date would prejudice the insurer.

The arbitrator also refused to add the travelling expenses issue because it had not been formally mediated, which is a statutory prerequisite under the Insurance Act.

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

The insurer denied the claims, and the matter proceeded to arbitration.

The applicant failed to attend the pre-hearing, settlement discussion, and the scheduled arbitration hearing without providing notice.

The arbitrator dismissed the application due to the applicant's failure to prove his claim.

Finding the applicant's conduct to be an abuse of process, the arbitrator ordered the applicant to pay the insurer's arbitration expenses in the amount of $1,727.83.

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

In his application, he falsely stated he was unemployed to protect his workers' compensation benefits.

The insurer assessed his claim for non-earner benefits and incurred expenses before denying the claim.

The appellant later revealed his true employment status and sought income replacement benefits.

The insurer refused to pay, relying on section 48 of the SABS-1996 for material misrepresentation.

The Director's Delegate upheld the arbitrator's decision, finding that the misrepresentation of employment status was material to both benefit claims and that section 48 permits an insurer to terminate entitlement to benefits even if no payments have yet been made.

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

He returned to his pre-accident employment for over three years before being laid off due to lack of work, and later worked another job for six months before being laid off again.

He subsequently claimed weekly income benefits, arguing he was continuously disabled.

The arbitrator dismissed the application, finding that the applicant's successful return to suitable employment for several years demonstrated he was not continuously prevented from engaging in suitable employment as required by section 12(5)(b) of the Schedule.

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

The applicant was injured when the TTC bus she was riding stopped suddenly.

She claimed ongoing income replacement benefits, medical benefits for physiotherapy and massage, and rehabilitation benefits for increased auto insurance premiums.

The insurer argued the claim was time-barred.

The arbitrator found the claim was not time-barred because the insurer's termination letters did not constitute a valid refusal under the Smith v. Co-operators standard.

However, on the merits, the arbitrator dismissed all claims.

Medical evidence, including from the applicant's own treating practitioners, indicated her ongoing symptoms were related to pre-existing chronic conditions rather than the accident, and she did not suffer a substantial inability to perform the essential tasks of her employment.

The applicant was injured while fleeing a multi-vehicle collision as a pedestrian.

She applied for statutory accident benefits from Royal, claiming she was an insured person under her son's automobile insurance policy.

Royal responded as the first insurer but denied she was an insured person.

The arbitrator found that the applicant was not listed on the policy and rejected her claim that there was a binding oral contract to include her, applying the parol evidence rule.

The arbitrator concluded the applicant was not an 'insured person' under the policy and not entitled to seek further accident benefits from Royal.

The applicant sustained a serious traumatic brain injury in a motor vehicle accident and received medical and rehabilitation benefits for ten years.

The insurer denied further benefits after the ten-year anniversary pursuant to subsection 6(3) of the Statutory Accident Benefits Schedule.

The applicant argued that her ongoing treatments should be covered under the exception for single treatments delivered in stages.

The arbitrator dismissed the claims, finding that the ongoing expenses for items such as pedicures, chiropractic care, and assistive devices were continuous series of treatments rather than a single service bridging the limitation period.

The applicant sought arbitration for various statutory accident benefits following a motor vehicle accident.

Neither the applicant nor his representative appeared at the hearing.

The arbitrator dismissed the application for arbitration due to the absence of evidence.

The insurer sought expenses, including the assessment fee, but the arbitrator noted the statutory authority to award the assessment fee had been repealed.

The arbitrator ordered the applicant to pay $1,500 in expenses.

The issue of whether the applicant's representative should personally pay $342 in disbursements was deferred to allow the representative an opportunity to make written submissions as required by the Insurance Act.

The applicant's representative brought a motion to withdraw from the arbitration.

The insurer sought an order requiring the representative to personally pay costs previously awarded against the applicant, alleging the representative violated the Code of Conduct.

The arbitrator permitted the withdrawal on consent.

Finding that the representative made deliberate misrepresentations to the tribunal and failed to produce documents, the arbitrator applied section 282(11.2) of the Insurance Act and ordered the representative to personally pay $1,500 in expenses to the insurer.

The applicant was injured in a motor vehicle accident and sought payment for two treatment plans for massage therapy to treat chronic pain.

The insurer denied the claims, relying on various medical and DAC reports.

The arbitrator found the applicant's testimony credible that massage therapy provided temporary pain relief, which in turn allowed her to engage in active exercise to improve her strength and endurance.

The arbitrator gave little weight to the insurer's medical reports, noting they either did not address massage therapy or lacked sufficient reasoning.

The arbitrator concluded that the massage therapy was a reasonable and necessary medical benefit under section 14 of the Statutory Accident Benefits Schedule and ordered the insurer to pay the claimed amount of $5,190 plus interest.

Following a preliminary issue hearing where the applicant was precluded from proceeding to arbitration due to late notice of his intention to apply for statutory accident benefits, the insurer sought its arbitration expenses.

The arbitrator found that the applicant's conduct, including failing to attend the hearing and delaying the insurer's ability to assess his medical requirements, constituted an abuse of process.

The insurer was awarded its reasonable expenses of $1,473.90.

The Applicant applied for arbitration after the Insurer terminated his weekly income replacement benefits following a motor vehicle accident.

The Applicant's agent withdrew from the record after being unable to contact the Applicant.

The Applicant failed to attend the arbitration hearing.

The Arbitrator dismissed the Applicant's claims for income replacement benefits, medical benefits, and interest, as the Applicant failed to meet the burden of proof.

The Insurer's claim for a return of its assessment fee was also dismissed due to a lack of jurisdiction under the amended Insurance Act.

The issue of expenses was deferred.

The applicant was injured in a motor vehicle accident and sought payment from her insurer for a catastrophic impairment assessment report and a psycho-vocational assessment.

The insurer denied payment, arguing the reports were not reasonable or necessary.

The arbitrator found that both assessments were reasonable and necessary under section 24 of the Statutory Accident Benefits Schedule.

The catastrophic impairment report was required to complete the application for determination of catastrophic impairment, and the psycho-vocational report was necessary to facilitate the applicant's reintegration into the labour market.

The insurer was ordered to pay the costs of both reports.

The applicants claimed statutory accident benefits following two alleged motor vehicle accidents on July 15 and July 30, 2002.

The insurer denied the claims, arguing that the incidents did not meet the definition of an "accident" under section 2(1) of the Statutory Accident Benefits Schedule.

At a preliminary issue hearing, the arbitrator heard evidence from the applicants and three accident reconstruction experts retained by the insurer.

The arbitrator found the applicants' accounts of both incidents to be unreliable and implausible.

Relying on the expert evidence, which demonstrated that the vehicle damage was inconsistent with the applicants' descriptions, the arbitrator concluded that the applicants were not involved in accidents within the meaning of the Schedule and were therefore precluded from proceeding to arbitration.

The applicant sought to reopen an arbitration hearing to introduce fresh evidence regarding a fall and subsequent injuries that occurred after the conclusion of the evidence but before closing arguments.

The applicant claimed the fall was related to the motor vehicle accident and affected her ongoing entitlement to income replacement benefits.

The arbitrator applied the Palmer test for fresh evidence and granted the motion, finding that the circumstances were exceptional and the new evidence was relevant, reasonably capable of belief, and could affect the result.

Following a decision on statutory accident benefits where the applicant was successful on only one of three issues, the applicant sought her arbitration expenses.

The arbitrator considered the criteria under section 12(2) of the Expense Regulation, including the applicant's limited success and the complexity of the issues.

The arbitrator awarded the applicant 25% of her arbitration expenses, noting that she argued her claims in good faith despite discrepancies in the evidence.