OFSCDRS 2005

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

After failing to attend medical examinations, pre-hearings, and failing to communicate with his counsel, the insurer brought a motion to dismiss the application and sought expenses against both the applicant and his counsel.

The applicant's counsel also brought a motion to withdraw as representative of record.

The arbitrator deemed the application withdrawn due to the applicant's failure to pursue his claim.

The applicant's counsel was permitted to withdraw and was not held personally liable for the insurer's expenses, as they acted within the normal scope of representation.

The applicant was ordered to pay $750 in expenses to the insurer.

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

In a previous decision, the insurer successfully defended the claim for income replacement benefits, while the applicant recovered a small amount for a functional capacity evaluation.

On the issue of expenses, the arbitrator found that both parties unnecessarily prolonged the hearing.

The applicant failed to produce hospital records on a timely basis, and the insurer's counsel conducted lengthy and unhelpful cross-examinations regarding the applicant's pre-existing psychiatric illness.

Consequently, the arbitrator ordered that each party bear their own expenses of the arbitration proceeding.

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

The insurer terminated income replacement and housekeeping benefits based on insurer examinations.

The applicant sought arbitration.

By the time of the hearing, the insurer had paid or agreed to pay most of the disputed benefits.

The remaining issues concerned a claim for one week of income replacement benefits, a small amount of interest, and whether the insurer was liable to pay a special award under s. 282(10) of the Insurance Act for unreasonably withholding or delaying payments.

The arbitrator dismissed the claims for the additional week of benefits and the specific interest amount.

However, the arbitrator found that the insurer acted unreasonably in its initial termination of benefits and in delaying payment of several medical and rehabilitation expenses, as well as interest on various late payments.

The arbitrator ordered the insurer to pay special awards on these amounts, with the exact quantum to be calculated by the parties based on established principles.

Following a decision on the merits where the applicant was partially successful in claiming weight training and psychological assessment expenses, the parties could not agree on the costs of the arbitration.

The arbitrator applied the criteria in section 12(2) of the Expense Regulation and found that because success was divided and no party engaged in conduct that prolonged the proceeding, each party should bear its own expenses.

The insurer's request to recover its $3,000 assessment cost was also denied as it is not a recoverable expense under the regulation.

The applicant's daughter was fatally injured in a motor vehicle accident.

The applicant, who resides in Vietnam, applied for death benefits from the insurer, claiming she was principally dependent for financial support on her daughter.

The insurer denied the claim.

The arbitrator found that the applicant failed to establish the requisite degree of financial dependence, as she provided insufficient and inconsistent evidence regarding her sources of income, the amount of support received from her daughter versus her other children, and her monthly expenses.

The claim for death benefits was dismissed.

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

At the arbitration hearing, the insurer brought a preliminary motion to exclude the applicant's representative, a statutory accident benefits (SABS) representative, alleging an undisclosed conflict of interest.

The arbitrator found that the representative had a business relationship with a diagnostic facility to which he referred the applicant, creating an apprehension that he could receive a financial benefit.

The arbitrator also noted the representative's inappropriate conduct at the hearing and failure to promptly notify the insurer of his retainer.

The representative was excluded from the proceedings and ordered to personally pay $500 in expenses for causing unreasonable delay.

The insurer brought a motion to exclude the applicants' representative from the arbitration proceedings due to an alleged conflict of interest.

The representative was the sole director of a company that acted as a booking agent and promoter for the medical assessment facility used by the applicants.

The arbitrator found that the representative had a direct or indirect financial interest in the acceptance of the facility's technology as a compensable benefit, which he failed to disclose to the insurer.

Applying the test from MacDonald Estate, the arbitrator concluded the representative was in a conflict of interest and excluded him from representing the applicants to preserve the integrity of the hearing process.

The applicant was injured in a motor vehicle accident and applied for income replacement benefits (IRBs) more than two years after the insurer's initial denial.

The applicant argued she was entitled to IRBs based on a business plan for a catering business prepared before the accident.

The arbitrator held that the application was time-barred under section 51(1) of the Statutory Accident Benefits Schedule.

Furthermore, the arbitrator found that even if the application was timely, the applicant did not meet the requirements of section 4(3)1 because a business plan does not constitute a legitimate contract of employment to start work within one year.

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

The insurer terminated income replacement benefits in 1997 based on a DAC report.

The applicant applied for mediation and arbitration in 2003 and 2004.

The insurer argued the application was statute-barred under the two-year limitation period in section 281.1 of the Insurance Act.

The arbitrator found that the insurer failed to comply with section 49 of the Schedule by not informing the applicant of the dispute resolution process, meaning the limitation period never began to run.

However, the arbitrator rejected the applicant's argument that the insurer's breach automatically entitled him to ongoing income replacement benefits without proving entitlement on the merits.

The insurer raised a preliminary issue seeking to exclude the applicant's statutory accident benefits representative from the arbitration hearing due to an undisclosed conflict of interest.

The representative had a business relationship with a medical assessor to whom he referred the applicant for a digital motion x-ray.

The arbitrator found that this relationship created an appearance of a possible or potential conflict of interest, as the representative could receive a financial benefit.

Applying the principles from civil litigation regarding fiduciary duties, the arbitrator concluded that the failure to disclose the conflict was an unfair or deceptive practice under the Insurance Act.

The representative was excluded from the hearing pursuant to the Statutory Powers Procedure Act.

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

The applicant failed to appear at the arbitration hearing.

The arbitrator stayed the proceeding to allow the applicant time to provide an explanation, but no correspondence was received and mail sent to the applicant's last known address was returned.

The application was dismissed.

Following a preliminary issue hearing where the insurer was successful in establishing that the applicant was not catastrophically impaired, the arbitrator determined the issue of arbitration expenses.

The arbitrator awarded the applicant 20% of his expenses, noting that while the insurer was successful on the principal issue, the applicant succeeded on secondary issues and the insurer failed to meaningfully participate in settlement discussions.

The applicant was awarded $3,047.89 in expenses.

The applicant was injured in a pedestrian knockdown and sought ongoing income replacement and medical benefits.

The insurer terminated benefits, alleging the applicant was exaggerating her symptoms and sought repayment of an overpayment.

The arbitrator found the applicant's presentation of chronic pain and emotional impairments to be genuine, rejecting the insurer's expert who admitted a bias toward skepticism.

The applicant was awarded ongoing income replacement benefits as she was completely unable to engage in suitable employment.

The insurer's claim for repayment was dismissed as the overpayment resulted from an employer error, not the applicant's wilful misrepresentation.

Medical benefits were partially awarded.

The applicant's application for statutory accident benefits was previously dismissed after the applicant and his counsel failed to attend the hearing.

The insurer sought expenses of $6,723.58.

The arbitrator reduced the counsel hours claimed from 55 to 40 and adjusted the hourly rate to comply with the Legal Aid Services Act.

The arbitrator ordered the applicant to pay $3,588.72 in expenses to the insurer.

The arbitrator declined to order the applicant's counsel to pay any portion of the expenses personally under s. 282 of the Insurance Act, finding that the counsel did not cause unnecessary expenses or delays, and the fault lay with the client.

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

The insurer subsequently terminated his weekly income replacement benefits.

The arbitrator found that the insurer unreasonably withheld benefits by ignoring overwhelming medical evidence of the applicant's ongoing cognitive impairment and relying on flawed reports that supported termination.

The arbitrator characterized the insurer's conduct as wilful blindness.

The applicant was awarded $64,177 in arrears of income replacement benefits, $48,096 in interest, a special award of $39,295 under s. 282(10) of the Insurance Act, and $42,908 in arbitration expenses.

The insurer appealed an arbitration order requiring it to pay income replacement benefits, medical benefits, and a $15,000 special award to the claimant following a motor vehicle accident.

The insurer argued the arbitrator erred in accepting the claimant's pre-accident employment contract and finding him disabled from that prospective job.

The Director's Delegate dismissed the appeal regarding the benefits, finding the arbitrator's conclusions were supported by the evidence and no error of law occurred.

However, the appeal was allowed in part regarding the special award.

The Director's Delegate found the arbitrator erred in her analysis by penalizing the insurer for relying on a Designated Assessment Centre report and for an adjuster's poor performance as a witness.

The special award was reduced by 50 percent to $7,500.

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

The insurer denied the claims, relying on engineering reports suggesting the accident did not occur as reported and may have been staged.

The applicant failed to attend the arbitration hearing.

The arbitrator found that the applicant failed to prove she was involved in an accident or sustained an impairment, dismissing all claims for benefits.

The applicant was ordered to pay the insurer's arbitration expenses due to her failure to attend and pursue her claim, which rendered the proceeding improper, vexatious, and unnecessary.

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

The insurer denied a treatment plan for massage therapy based on a negative Designated Assessment Centre (DAC) report.

In a previous arbitration decision, the arbitrator found the treatment plan was reasonable and necessary, and awarded the medical benefit.

The current issue was when interest on the overdue payment started to run.

The insurer argued that based on previous appeal decisions, interest should not run until the date of the arbitration decision because of the negative DAC report.

The arbitrator distinguished the appeal decisions, finding that the DAC report was flawed and the insurer had ample evidence to support the claim.

The arbitrator held that the interest provisions are compensatory and remedial, and that interest started to run 14 days after the treatment plan was submitted to the insurer.

State Farm appealed an arbitrator's decision that Mrs. Scott's HOOPP disability retirement pension was not deductible from her income replacement benefits (IRBs).

Mrs. Scott sought a variation of the IRB quantum.

The Director's Delegate dismissed the appeal, finding the HOOPP pension is a non-indemnity payment akin to a regular pension and thus not deductible from IRBs to prevent double recovery.

The variation application was granted in part, finding an error in the original order regarding the net versus gross amount of long-term disability benefits and the failure to account for CPP disability benefits.

The exact calculation of IRBs was remitted to the arbitrator.

The insurer sought to add a repayment issue to the arbitration.

The applicant's representative refused to consent, claiming the issue was unmeritorious and statute-barred, but provided no evidence or detailed submissions.

The arbitrator found that the insurer's claim was not plainly and obviously devoid of merit and that adding the issue would avoid a multiplicity of proceedings.

The arbitrator allowed the insurer to amend its response to include the repayment issue and ordered the applicant to pay $250 in expenses due to the representative's contumacious refusal to consent.