OFSCDRS 2005

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

A dispute arose regarding the format of the pre-hearing conference.

The insurer, having retained out-of-town counsel, requested a teleconference, while the applicant requested an in-person hearing in Toronto.

The arbitrator held that the applicant's choice of venue should not be lightly abrogated and ordered that the resumption of the pre-hearing take place in person at the Commission's offices in Toronto.

The applicant sought statutory accident benefits after slipping and falling on a snowbank while disembarking from a public transit bus.

The insurer denied benefits, arguing the injuries were not directly caused by the use or operation of the bus.

The arbitrator found the applicant's account credible and determined that disembarking was integral to the use of the bus.

The arbitrator concluded that the use or operation of the bus directly caused the injuries, satisfying the definition of an 'accident' under section 2(1) of the Statutory Accident Benefits Schedule.

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

After failing to resolve disputes through mediation, he applied for arbitration.

The applicant failed to comply with a prior order to produce documents and sign authorizations.

The arbitrator removed the applicant's former representative from the record at his request and ordered the arbitration stayed until the applicant complied with the production order.

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

The arbitrator found that the applicant was entitled to IRBs and housekeeping benefits until November 30, 2003, as the medical evidence indicated he was substantially unable to perform his employment and housekeeping tasks until that time.

The arbitrator also awarded medical benefits for chiropractic treatment and assistive devices, finding them reasonable and necessary.

However, the applicant's claim for a special award was dismissed, as the insurer's decision to terminate benefits was not unreasonable given the contradictory information and medical evidence available at the time.

In a pre-hearing conference regarding a dispute over statutory accident benefits, the applicant sought the insurer's reasons for continuing to deny income replacement benefits and its response to her claim for a special award.

The insurer objected, arguing the request amounted to discovery, which is not provided for in the Commission's rules.

The arbitrator ordered the insurer to provide specific particulars of its response to the special award claim within 20 days of receiving the applicant's particulars, finding that meaningful pleadings are necessary to facilitate a fair and expeditious dispute resolution process.

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

The insurer denied entitlement, and the parties proceeded to arbitration.

The applicant's representative was removed from the record with her consent prior to the hearing.

The applicant failed to attend the hearing despite receiving proper notice.

As no evidence was tendered to support the application, the arbitrator dismissed the application and ordered the applicant to pay the insurer's expenses fixed at $1,977.33.

The applicant was injured in a motor vehicle accident and sought a rehabilitation benefit for a retraining course.

The insurer requested production of the applicant's income tax summaries from 1997 to 2002 to assess the reasonableness of the retraining by comparing potential earnings to pre-accident earnings.

The arbitrator held that the tax records were not relevant because the applicant's income replacement benefits had been calculated based on a prospective contract of employment rather than retrospective pre-accident earnings.

The insurer's request for production was denied.

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

Disputes arose and the applicant applied for arbitration at the Financial Services Commission of Ontario.

During a hearing to determine a motion, the applicant requested to withdraw his application without costs.

The insurer consented to the request.

The arbitrator granted the request and permitted the applicant to withdraw the application without costs.

The insurer brought a motion to adjourn an upcoming arbitration hearing so that the insured could attend an Examination Under Oath regarding her delayed application for statutory accident benefits.

The arbitrator denied the adjournment request, finding that the insurer's request was made too close to the hearing date despite having ample prior opportunity.

Furthermore, the arbitrator held that there is no jurisdiction to adjourn an arbitration hearing as a remedy for an insured's failure to attend an Examination Under Oath, as the Statutory Accident Benefits Schedule provides an express remedy of benefit suspension.

The issue of expenses was deferred to the hearing arbitrator.

An arbitration application was submitted to the Financial Services Commission of Ontario in the applicant's name by a paralegal firm.

The applicant later stated he had not authorized the proceeding.

The insurer sought its expenses for responding to the unauthorized application.

The arbitrator found that the paralegal commenced the proceeding without the applicant's authority and caused the insurer to incur expenses without reasonable cause.

The application was withdrawn, and the paralegal was ordered to personally pay the insurer's expenses pursuant to section 282(11.2) of the Insurance Act.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for chiropractic treatment.

The insurer refused to pay and sought permission to call three expert witnesses at the upcoming hearing, contrary to Rule 42.4 of the Dispute Resolution Practice Code which limits parties to two experts without permission.

The arbitrator applied the criteria from Burgess v. Wu and R. v. Mohan, emphasizing the tribunal's mandate to provide a quick and inexpensive resolution.

Given that the amount in dispute was only $1,350, the arbitrator found the time and cost of calling three experts disproportionate and denied the insurer's request to call more than two expert witnesses.

The applicant sought statutory accident benefits after falling while attempting to board a TTC bus.

The insurer denied the claim, arguing the incident did not meet the definition of an 'accident' under section 2(1) of the Statutory Accident Benefits Schedule.

The arbitrator found the applicant's evidence credible, concluding that the closing of the bus door and the bus pulling away caused her to lose her balance and fall.

The arbitrator held that the injuries were directly caused by the use or operation of an automobile, satisfying the definition of an accident.

The applicant sought income replacement benefits following a motor vehicle accident, claiming he was substantially unable to perform his pre-accident job as a retail investigator.

The insurer terminated benefits and sought repayment of an overpayment.

The arbitrator dismissed the applicant's claim, finding he lacked credibility and had misrepresented his pre-accident medical condition, the nature of his injuries, and the reasons for leaving his employment.

The arbitrator concluded the applicant left his job due to poor performance rather than accident-related injuries.

The applicant was ordered to repay $1,140.30 in overpaid benefits.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for chiropractic treatment, housekeeping services, and a functional capacity evaluation.

The arbitrator found the applicant's credibility was compromised by inconsistent statements and questionable documentation.

The arbitrator awarded $673 for the outstanding balances of the first two chiropractic treatment plans, finding them reasonable and necessary.

The claims for further chiropractic treatment, housekeeping benefits, and the functional capacity evaluation were dismissed for lack of persuasive evidence.

Interest was awarded on the overdue medical benefits.

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

During the pre-hearing process, the applicant changed representatives without notifying the Commission or the insurer, resulting in wasted time and adjourned hearings.

The insurer brought a motion for expenses for time thrown away.

The arbitrator granted the motion, awarding the insurer $410.38 in expenses.

Pursuant to subsection 282(11.2) of the Insurance Act, the arbitrator ordered the applicant's prior representatives to personally pay 50% of the expenses for failing to advise that they no longer represented the applicant, causing unreasonable delay and wasted expenses.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits, including housekeeping and home maintenance benefits.

The insurer denied the claim and sought an orthopaedic examination under section 42 of the Statutory Accident Benefits Schedule.

The applicant refused to attend, arguing he had not yet applied for the benefit.

The insurer argued the applicant was disentitled for failing to attend the examination.

The arbitrator held that the applicant had not applied for the benefit at the time the examination was requested, as he had not submitted the required Application for Expenses and explicitly stated he had not applied.

Therefore, he was not required to attend the examination.

The issue of whether the applicant had a reasonable explanation for failing to apply within 30 days of receiving the forms was deferred to the main hearing.

The applicant sought to withdraw her application for arbitration at the Financial Services Commission of Ontario in order to pursue her claims in the Superior Court of Justice.

The insurer opposed the withdrawal but requested costs, including costs against the applicant's counsel personally, if the withdrawal was granted.

The Arbitrator permitted the withdrawal on the condition that the applicant cannot re-apply for arbitration on the same issues.

The Arbitrator awarded $500 in costs to the insurer, payable by the applicant, finding the arbitration application was unnecessary given the subsequent choice to proceed in court.

The request for costs against counsel personally was dismissed due to a lack of evidence regarding who made the strategic decisions.

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

The applicant sought further income replacement benefits, arguing he was unable to return to his pre-accident employment as a concrete cutter due to physical and psychological impairments.

The arbitrator found the applicant's physical impairment evidence unreliable, but accepted the psychological evidence that he suffered from major depressive disorder and anxiety which prevented him from working.

The arbitrator preferred the applicant's psychological expert over the insurer's expert.

The applicant was awarded income replacement benefits for the disputed period.

Claims for attendant care and housekeeping were withdrawn, and a claim for the cost of a functional abilities evaluation was denied for failing to seek prior approval.

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

The applicant's representative brought a motion to be removed from the record due to a complete breakdown in the relationship with the applicant.

The applicant did not oppose the motion and requested a brief adjournment to obtain new representation.

The arbitrator granted the motion, removing the representative from the record, and adjourned the hearing to allow the applicant to retain new counsel and fulfill outstanding undertakings.

The insurer appealed an arbitration decision ordering it to pay interest on outstanding income replacement benefits from the date it stopped paying them following a negative designated assessment centre (DAC) report.

The Director's Delegate dismissed the appeal, finding that when it is finally determined that benefits should not have been stopped, the requirement to pay 'any amounts under the benefit that were not paid' includes compound interest from the date of the negative DAC.