OFSCDRS 2006

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

The insurer denied his entitlement to weekly income replacement benefits.

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

The arbitrator proceeded in his absence pursuant to Rule 37.7 of the Dispute Resolution Practice Code.

As the applicant presented no evidence, he failed to meet his burden of proof, and his claims were dismissed.

The insurer appealed an arbitrator's interim order requiring it to pay the claimant's nanny expenses as a rehabilitation benefit under section 15(5)(l) of the SABS-1996.

The claimant, who suffered psychological impairments from a motor vehicle accident, sought the expenses to care for her child born after the accident.

The Director's Delegate allowed the appeal, finding that the arbitrator erred in law.

The Delegate held that child care expenses are exclusively governed by the caregiver and dependant care provisions of the SABS and cannot be recovered as a general rehabilitation benefit under section 15.

The applicant applied for arbitration at the Financial Services Commission of Ontario after the insurer terminated his statutory accident benefits.

The applicant failed to attend the hearing and presented no evidence to support his claims.

The arbitrator proceeded in his absence, dismissed his claims for income replacement benefits, medical benefits, and examination costs, and ordered him to pay the insurer's expenses fixed at $1,300.

The applicant, who was catastrophically injured in a motor vehicle accident and resides in a long-term care facility, sought additional attendant care benefits for personal care, financial management, and clothing care provided by his family.

The arbitrator found that the daily care provided by the facility was reasonable and adequate, denying additional daily personal care benefits.

However, the arbitrator awarded a nominal monthly amount of $37.10 for financial management and clothing care services provided by family members, interpreting section 16 of the Schedule conjunctively to allow concurrent expenses for a facility and an aide.

Claims for a special award were dismissed, but interest on overdue payments was granted.

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

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

The arbitrator found the Applicant's evidence and her medical assessors' opinions credible, establishing that her physical and psychological impairments substantially prevented her from performing her pre-accident employment and housekeeping tasks.

The arbitrator rejected the Insurer's assessors' evidence as flawed and unpersuasive.

The Applicant was awarded income replacement and housekeeping benefits for the 104-week period, with interest.

Claims for post-104 week benefits were dismissed on a technical basis without prejudice.

The claim for a special award was dismissed as the Insurer's reliance on its assessors, though ultimately unsuccessful, was not unreasonable.

Following a decision dismissing the applicant's claim for statutory accident benefits for overseas airline tickets, the insurer sought its expenses for the arbitration proceeding.

The arbitrator applied the criteria under section 12(2) of Ontario Regulation 664 and found that the insurer was completely successful.

The arbitrator rejected the applicant's argument that her modest means should preclude a costs award, noting that only the prescribed criteria could be considered.

The insurer was awarded $1,875.29 in expenses.

The insurer applied to vary or revoke an arbitration order regarding the quantum of income replacement benefits, arguing the insured was self-employed rather than employed.

The arbitrator dismissed the application, finding that the insurer's challenge to the previous arbitrator's ruling on jurisdiction was effectively an appeal, not an error in the order.

Furthermore, the evidence regarding employment status was not 'unavailable' at the original hearing; rather, the insurer failed to act diligently to mediate the issue in a timely manner.

The applicant was injured in a motor vehicle accident and sought income replacement benefits, medical and rehabilitation benefits (including a Tempur mattress and a lightweight laptop), and a neuropsychological re-assessment.

The arbitrator found that the applicant did not suffer a substantial inability to perform the essential tasks of her pre-accident employment, as she continued to work and earn similar income post-accident.

The claims for the mattress, laptop, and re-assessment were dismissed as they were not proven to be reasonable and necessary.

The insurer's claim for repayment of advances was also dismissed due to lack of proper notice within the 12-month limitation period.

The applicant's counsel brought a motion to be removed as solicitors of record for the applicant in an upcoming arbitration.

Counsel submitted that they had lost contact with the applicant despite multiple attempts to reach him at his last known address and telephone numbers, including a number in New Jersey.

The insurer did not object to the withdrawal but requested a peremptory notice of hearing.

The arbitrator found a breakdown in the solicitor-client relationship and permitted the firm to withdraw without terms.

The request for a peremptory notice was denied as unnecessary.

The applicant sought an assessment of expenses following a successful arbitration for statutory accident benefits and a subsequent appeal.

The insurer argued the request was out of time under Rule 79.1 of the Dispute Resolution Practice Code.

The arbitrator exercised discretion under Rule 81.1 to set aside the 30-day time limit, finding it reasonable that the applicant waited until the appeal was resolved.

The arbitrator awarded the applicant his expenses, including an hourly rate of $150 for his counsel and $45 for a highly experienced law clerk who also acted as an interpreter.

Total expenses of over $51,000 were awarded, including disbursements and the costs of the assessment hearing.

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

The insurer refused to pay for one year of treatment, arguing it was not reasonable or necessary.

The arbitrator dismissed the application, finding the applicant's evidence of accident-related pain unreliable due to his pre-accident medical history and pre-occupation with his health.

The arbitrator rejected the opinions of the applicant's chiropractors, citing methodological flaws, deficient record-keeping, and a failure to consider the applicant's full medical history.

The arbitrator accepted expert evidence that the applicant would benefit more from cognitive therapy and an exercise program rather than ongoing passive physical therapy.

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

The Insurer stopped payment of caregiver and housekeeping benefits, alleging the Applicant failed to attend scheduled insurer examinations.

On a preliminary issue hearing, the Arbitrator found that the Insurer failed to provide adequate notice of the examinations as required by the Statutory Accident Benefits Schedule.

Consequently, the Applicant was not precluded from receiving the benefits under s. 42(8).

The applicant was injured when he rode his bicycle into a parked trailer attached to an automobile at night.

He applied for statutory accident benefits, which the insurer denied on the basis that the incident did not meet the definition of an 'accident' under section 2(1) of the Statutory Accident Benefits Schedule.

The arbitrator found that the parked trailer constituted an automobile and that parking is an ordinary use of an automobile.

The arbitrator concluded that the applicant's injuries were directly caused by the use or operation of an automobile, and therefore the incident qualified as an accident.

The applicant, having previously been found catastrophically impaired, sought determination of the quantum of attendant care benefits, interest, and a special award.

Based on the parties' agreement, the arbitrator fixed the net attendant care benefits at $100,787.65 and awarded interest on both attendant care and housekeeping benefits.

The arbitrator further ordered the insurer to pay a special award of $150,000 under section 282(10) of the Insurance Act, finding that the insurer had unreasonably withheld and delayed benefit payments through multiple compounding breaches.

The applicant sought production of the insurer's adjusting notes up to the date of mediation in her claim for income replacement benefits following a motor vehicle accident.

The insurer had terminated benefits on the basis that her injuries were limited to a Grade II Whiplash Associated Disorder.

The applicant argued the notes were relevant to her claim for a special award, as medical evidence suggested her injuries fell outside the WAD II framework.

The arbitrator granted the motion, finding sufficient foundation to support the applicant's entitlement to review the claims handling process.

The insurer brought a preliminary issue motion seeking an order that a proposed orthopaedic examination of the applicant is reasonably necessary under section 42 of the Statutory Accident Benefits Schedule.

The insurer argued the examination was needed to reassess its termination of the applicant's income replacement benefits, given contradictory opinions from a previous medical assessor.

The applicant opposed the motion, arguing there was no change in condition to warrant a further assessment.

The arbitrator found that the examination was reasonably necessary for the fair and effective adjusting of the claim, rather than to bolster the insurer's case for arbitration, and ordered the applicant to attend.

The insurer appealed an arbitrator's decision awarding interest on overdue medical benefits from 14 days after the receipt of the treatment plan.

The insurer argued that, based on previous appeal decisions, interest should only accrue from the date of the arbitrator's order because it had relied on a negative Designated Assessment Centre (DAC) report to deny the benefits.

The Director's Delegate dismissed the appeal, declining to follow the previous appeal decisions.

The Delegate held that the requirement to pay medical benefits does not depend on a positive DAC report or an arbitrator's decision, and that interest is mandatory and compensatory, flowing from a finding that benefits were payable and not paid on receipt of the required application documents.

The applicant's law firm brought a motion to withdraw as her representative, citing an inability to contact her to obtain instructions following a pre-hearing settlement offer.

The arbitrator dismissed the motion, noting that the firm failed to provide a supporting affidavit detailing its attempts to contact the client over the preceding months, relying instead only on recent affidavits of attempted service.

The dismissal was without prejudice to a further motion on better material, and the arbitration hearing dates were adjourned to allow further attempts to contact the applicant.

The applicant in a statutory accident benefits dispute brought a motion to remove the insurer's solicitors from the record, alleging a conflict of interest involving a private investigator.

The applicant also summoned several lawyers from the insurer's firm.

The insurer moved to quash the summonses.

The applicant subsequently withdrew her motion.

The insurer sought its expenses for both motions.

The arbitrator found the applicant's motion was unnecessary and tended to prolong, obstruct, or hinder the proceedings.

The insurer was awarded $2,500 in expenses.

The applicant was injured in a motor vehicle accident when she fell from a transit bus.

She sought payment for physiotherapy and acupuncture treatments under the Statutory Accident Benefits Schedule after the insurer denied them.

The arbitrator found that the March 2002 physiotherapy treatment plan was reasonable and necessary, as the applicant was only partially recovered and a gradual reduction in treatment frequency was appropriate.

However, the April 2002 physiotherapy plan was denied because the passive treatments were no longer providing sustained relief.

The claim for acupuncture was dismissed because no treatment plan was ever submitted to the insurer.

Interest was awarded on the approved amount from the date of the decision, as the clinic had failed to advise the applicant of her personal liability or consider independent medical assessments.