OFSCDRS 2006

The insurer brought a motion for a preliminary order to compel the insured to attend a further insurer's examination under section 42 of the Statutory Accident Benefits Schedule.

The arbitrator dismissed the motion because the insurer failed to provide the insured with the mandatory notice required by subsection 42(4), which sets out the reasons, type, and details of the examination.

The arbitrator held that compliance with the notice provision cannot be waived by the parties, as the information is necessary to determine whether the examination is reasonably required.

Each party was ordered to bear their own expenses.

The insurer brought a motion for preliminary issues seeking an order requiring the insured to produce a co-op placement file and attend three insurer examinations pursuant to section 42 of the Statutory Accident Benefits Schedule.

The insured consented to using best efforts to produce the file.

The arbitrator dismissed the request for the insurer examinations, finding that the insurer's notice was invalid due to incomprehensible wording and that the assessments were sought to bolster the insurer's case at the upcoming arbitration rather than to adjust the claim.

The insurer appealed an arbitrator's preliminary decision that the claimant was not precluded from arbitration despite giving notice of his claim more than four years after the motor vehicle accident.

The claimant was 14 years old at the time of the accident.

The Director's Delegate upheld the arbitrator's finding that the claimant had a reasonable explanation for the delay under s. 31(1) of the SABS, considering his youth, his parents' ignorance of the law, their fear of authority, and the lack of prejudice to the insurer.

The appeal was dismissed.

The appellant appealed an arbitrator's decision denying him income replacement benefits and ordering repayment of benefits paid after January 28, 2004.

The appellant argued the insurer lacked a basis for its termination notice because the medical reports were allegedly received after the notice was sent.

The Director's Delegate rejected this argument, finding the reports were faxed prior to the notice.

The Delegate also found no error in the arbitrator's assessment of the appellant's credibility, employment status, and medical evidence.

The appeal was dismissed.

Following a successful interim motion for statutory accident benefits for nanny services, the applicant sought her legal expenses and a special award.

The arbitrator awarded the applicant her legal expenses of $7,750.40, finding the motion was necessitated by the insurer's refusal to comply with the 'pay now, dispute later' provisions of the Schedule.

The arbitrator also granted a maximum special award of $18,426.62 under s. 282(10) of the Insurance Act, concluding that the insurer unreasonably withheld payments mandated by a positive Designated Assessment Centre (DAC) report.

In a dispute over statutory accident benefits, the insurer brought a motion for production of the applicant's OHIP summary, family physician records, and physiotherapy/chiropractic records.

The applicant cross-moved for production of the adjuster's file.

The arbitrator ordered the applicant to produce medical records dating back to one year prior to a previous 2003 accident, finding the insurer's request for older records premature and too broad.

The arbitrator also ordered the insurer to produce the adjuster's file up to the date of the application for mediation, noting that documents created after that date may be subject to litigation privilege.

The applicant sought statutory accident benefits for rehabilitation and care services following a 1993 motor vehicle accident.

The insurer denied the claims, arguing the applicant's pervasive physical, cognitive, and psychological conditions were not caused by the accident.

The arbitrator dismissed the applicant's claims, finding she failed to prove on a balance of probabilities that the accident materially contributed to her impairments.

The arbitrator noted a complete absence of pre-accident medical records, relying solely on the applicant's unreliable self-reporting, and drew an adverse inference from her failure to call pre-accident treating physicians or lay witnesses to corroborate her pre-accident health and functional abilities.

Following an arbitration decision awarding the applicant non-earner benefits for approximately 50 weeks, both parties sought their expenses of the hearing.

The insurer had made an offer to settle six days before the hearing, which was slightly better than the arbitration outcome.

The arbitrator found that the parties had mixed success and that the offer to settle should be given no weight because it was delivered only three business days before the hearing, giving the applicant insufficient time to consider it.

The arbitrator ordered that the parties bear their own expenses.

The insurer brought a motion for an order permitting it to schedule post-104 week examinations of the insured and requiring the insured to attend.

The arbitrator dismissed the motion, finding that an order permitting the scheduling of examinations was unnecessary as section 42 of the Statutory Accident Benefits Schedule already permits insurers to schedule them.

Furthermore, the arbitrator held that she lacked jurisdiction to order an insured to attend an examination, noting that the insurer had not yet served the insured with the required notice under section 42(4).

The applicant was injured when she slipped and fell on a bus.

She applied for statutory accident benefits.

The insurer deducted amounts she received from a private disability policy from her pre 104-week income replacement benefits and denied her post 104-week benefits.

The arbitrator held that the private policy was a non-indemnity policy and its benefits were not deductible.

The arbitrator also found that the applicant suffered a complete inability to engage in suitable employment due to chronic pain and was entitled to post 104-week benefits.

A special award of $1,500 was granted due to the insurer's unreasonable delay in adjusting the claim.

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

The insurer denied further physiotherapy, and the applicant failed to attend two scheduled Designated Assessment Centre (DAC) appointments.

The insurer argued her claims should be barred.

On a preliminary issue, the arbitrator found the applicant had a reasonable excuse for missing the first appointment due to an emergency move to a shelter.

While she lacked a reasonable excuse for the second missed appointment, the insurer improperly demanded immediate cash repayment of DAC no-show fees before scheduling a third appointment, contrary to the Schedule.

The arbitrator ruled the applicant's claims for medical and rehabilitation benefits could proceed to a full hearing.

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

The insurer paid the treatment provider directly, but the applicant's agent proceeded with an arbitration application.

The insurer sought costs against the agent personally under section 282(11.2) of the Insurance Act for causing expenses to be incurred without reasonable cause.

The arbitrator found that the agent ignored communications regarding the settlement and delayed withdrawing the application, constituting an abuse of process.

The agent was ordered to personally pay the insurer's fixed expenses of $1,566.

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

The insurer stopped paying benefits at the 104-week mark without issuing a notice of stoppage or offering a designated assessment centre (DAC) evaluation, relying on a previous arbitration decision that found the applicant capable of working as a forklift operator.

The arbitrator held that the insurer was not entitled to ignore the procedural requirements of section 37 of the Statutory Accident Benefits Schedule.

The previous decision only determined the applicant's condition up to a specific date, and the insurer was required to provide a notice of stoppage and offer a DAC to allow the applicant to challenge the termination of benefits.

The appellant appealed an arbitrator's decision dismissing her claim for a treatment plan following a motor vehicle accident.

She argued the arbitrator should have given no weight to a Designated Assessment Centre (DAC) report because the assessors were not qualified as experts at the hearing.

The Director's Delegate dismissed the appeal, finding that the appellant failed to challenge the introduction of the DAC report or the assessors' qualifications during the hearing.

The Delegate held that it was too late to raise the issue of expert qualifications for the first time in final written submissions.

The insurer requested four medical and vocational examinations to assess the applicant's entitlement to post-104 week income replacement benefits.

The arbitrator found that the request for a functional abilities evaluation was reasonable, as it would provide relevant evidence about the applicant's physical ability to work.

However, the requests for an orthopaedic examination, a psycho-vocational assessment, and a 2-day situational assessment were dismissed.

The arbitrator held that the psycho-vocational and situational assessments constituted unreasonable invasions of privacy, particularly because the applicant had not put her psychological ability to work in issue, and the situational assessment raised potential civil liberties concerns.

The applicant attended a pre-hearing discussion for a statutory accident benefits dispute, having travelled from Sarnia and taken a day off work.

The insurer's representative failed to attend for personal reasons, but the insurer failed to provide advance notice to the applicant.

The arbitrator found that the applicant incurred needless expenses due to the lack of notice and awarded $300 in expenses to the applicant.

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

The insurer brought a motion to dismiss the application for arbitration after the applicant failed to obtain leave to proceed against the insurer, which was in receivership.

The applicant did not attend the motion hearing despite receiving notice.

The arbitrator declined to dismiss the application as frivolous or vexatious, but ordered that the application be deemed withdrawn due to the applicant's failure to attend and pursue his claim.

The Applicant applied for statutory accident benefits following an alleged motor vehicle accident.

The Insurer denied the benefits, alleging that the accident was staged and that the Applicant's vehicle was struck while stationary.

The Insurer relied on the reports of an investigator and two accident reconstruction experts who concluded the collision did not occur as described.

The Arbitrator found the Applicant to be a credible witness and accepted her version of events.

The Arbitrator gave little weight to the Insurer's expert reports because the experts did not examine the vehicles or interview the drivers, and relied on inaccurate information.

The Arbitrator concluded that the Applicant was involved in an accident as defined in section 2 of the Schedule.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for various medical treatments, medications, and the cost of reports and assessments.

The insurer denied the claims based on a DAC assessment that concluded further treatment was not reasonable or necessary.

The arbitrator found that the applicant's recovery was prolonged by pre-existing conditions and psychological issues, and that the multi-disciplinary treatments provided were reasonable and necessary up to a certain date.

The arbitrator awarded partial payment for the treatments and reports, and full payment for the medications.

The claim for a special award was dismissed as the insurer's reliance on its medical reports was not unreasonable.

The applicant was awarded interest and arbitration expenses.

The applicants applied for statutory accident benefits following an alleged motor vehicle accident.

The insurer terminated benefits and sought repayment, alleging the applicants wilfully misrepresented the circumstances of the accident.

Relying on uncontroverted expert accident reconstruction evidence, the arbitrator found the accident could not have occurred as described by the applicants.

The arbitrator concluded the applicants wilfully misrepresented material facts and ordered them to repay the income replacement, housekeeping, and medical benefits paid directly to them, totaling $14,536.12 for one applicant and $16,973.63 for the other, plus interest.

The applicants were also ordered to pay the insurer's arbitration expenses.