OFSCDRS 2007

In a pre-hearing decision regarding a claim for statutory accident benefits, the insurer sought to add the issue of the quantum of income replacement benefits and requested production of various pre-accident employment and medical records.

The arbitrator denied the request to add the issue of quantum, noting the insurer had previously agreed to the quantum and raising it now would prejudice the applicant and complicate the proceeding.

The arbitrator also denied the production requests, finding they were not properly raised or justified at this stage of the proceeding.

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

The insurer terminated her income replacement benefits after 16 weeks, arguing her injuries were limited to a WAD II neck injury.

The arbitrator found that the applicant suffered from a psychological impairment and chronic pain syndrome directly resulting from the accident, entitling her to ongoing income replacement benefits, housekeeping expenses, and the cost of a psychological assessment.

The arbitrator also awarded a special award against the insurer, finding it acted unreasonably by maintaining a closed mind and ignoring cogent medical evidence, including its own insurer's examination, that supported the applicant's claim.

Following the dismissal of the insured's application for statutory accident benefits, the insurer sought its expenses of the arbitration proceeding.

The insured's counsel did not file a response to the insurer's bill of expenses.

The arbitrator reviewed the claimed fees and disbursements, allowing the fees as claimed but disallowing a $1,112.00 disbursement for the attendance of a rheumatologist, finding the expert's opinion was neither necessary nor helpful.

The insurer was awarded total expenses of $8,795.97.

The applicant was injured in a motor vehicle accident and applied for statutory accident benefits, including income replacement benefits (IRBs) and housekeeping expenses.

The insurer denied IRBs due to concerns about the legitimacy of the applicant's job offer.

In a prior decision, the arbitrator found the job offer was valid.

In this hearing, the arbitrator determined the applicant was substantially unable to perform the essential tasks of the proposed employment for a period of approximately four months post-accident.

The arbitrator awarded IRBs at a rate based on the minimum wage for restaurant workers, rather than the higher amount claimed by the applicant.

The claim for housekeeping expenses was dismissed due to a lack of evidence regarding the specific services provided.

Interest was awarded from the date the prior decision validated the employment contract, as the applicant had failed to provide necessary information to the insurer before that time.

The applicant brought a motion seeking orders requiring the insurer to pay for transcripts from a previous arbitration, produce its entire accident benefits file, produce its Policy and Procedure Manual, and produce a copy of her medical file from Riverfront Medical.

The arbitrator denied the requests for the transcripts, the accident benefits file, and the manual.

The arbitrator found no jurisdiction to admit the transcripts without consent, that the file request was too late to assess privilege claims, and that the manual did not exist.

The insurer was ordered to produce the medical file at its expense.

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

The insurer argued that the applicant was precluded from coverage under section 1.8.4 of the Ontario Automobile Policy (OAP 1), which excludes coverage for persons who sell or repair automobiles as part of a business while involved in conducting that business.

The applicant and his brother had leased dealer plates to buy and sell cars for profit, but had only sold one car prior to the accident.

The arbitrator found that the enterprise was not sufficiently developed to be considered a business at the time of the accident.

Furthermore, even if it were a business, the insurer failed to prove that the applicant was involved in conducting that business when the accident occurred.

The arbitrator concluded that the applicant was not precluded from coverage.

The insurer appealed arbitration decisions that dismissed its motions to compel the insured to attend insurer examinations and ordered it to pay a special award for unreasonably delaying benefits.

The insured cross-appealed the denial of a special award for other periods of delay.

The Director's Delegate dismissed both appeals.

The Delegate found that the arbitrators did not err in law in refusing the insurer examinations, as the insurer had delayed its requests until after the arbitration process was well underway.

Furthermore, the insurer's concession of entitlement during the hearing precluded a finding that it was denied a fair hearing.

The Delegate upheld the special award, finding no basis to interfere with the arbitrator's assessment of the insurer's unreasonable conduct, and agreed that the insurer's delay while seeking a stay of an interim order was not unreasonable.

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

The applicant failed to attend two pre-hearing discussions and the scheduled hearing.

The applicant's solicitors brought a motion to be removed from the record due to a breakdown in communication, which was granted.

Due to the applicant's failure to attend and pursue the matter, the application was dismissed as an abuse of process.

The insurer was awarded its expenses of the arbitration fixed at $2,534.86.

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

The parties disputed entitlement to a medical benefit for a treatment plan and the cost of an in-home assessment.

The arbitrator found that the applicant was entitled to $502.00 for the treatment plan, as the treatment was reasonable and necessary up to a certain date.

However, the claim for the in-home assessment was dismissed because it was duplicative of an insurer's assessment and not reasonably required.

Interest was awarded on the overdue payment, and the issue of expenses was deferred.

The applicant was involved in a single motor vehicle rollover accident.

The insurer denied her claim for income replacement and housekeeping benefits, alleging she made a material misrepresentation by claiming she was the driver when her husband was actually driving.

The insurer relied on an anonymous tip and an accident reconstruction report.

The arbitrator weighed conflicting expert evidence on occupancy dynamics and injury biomechanics.

The arbitrator preferred the applicant's expert, finding his explanation of the applicant's head injury more cogent, and concluded on a balance of probabilities that the applicant was driving the vehicle.

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

The insurer denied various benefits, leading to arbitration.

On a preliminary motion, the arbitrator ruled that the applicant's claims for certain examination costs were barred because she failed to seek prior approval under s. 24(1.1) of the Schedule.

However, the arbitrator allowed the applicant to proceed with claims for treatment expenses incurred before the insurer first raised the lack of treatment plans, as the insurer had breached its duty to assist the applicant.

The arbitrator also ordered the insurer to produce portions of its accident benefits file up to the date of the second mediation application, but denied the applicant's request for the insurer's internal policies on lumping out claims.

The applicants applied for arbitration regarding their claims for statutory accident benefits following a motor vehicle accident.

Neither applicant attended the scheduled arbitration hearing, despite the Commission providing reasonable notice to their last known addresses.

The arbitrator proceeded in their absence pursuant to the Statutory Powers Procedure Act.

As the applicants tendered no evidence, they failed to discharge their burden of proof.

The arbitration applications were dismissed, and the insurer withdrew its claim for expenses.

The applicant was injured in a motor vehicle accident while driving his former wife's uninsured vehicle.

He applied for statutory accident benefits from the insurer of the other vehicle.

The insurer argued the applicant was excluded from receiving income replacement and housekeeping benefits under s. 30(1)(a) of the Schedule because he knew or ought reasonably to have known the vehicle was uninsured.

The arbitrator found that the applicant was principally responsible for arranging insurance on the vehicle and had been notified of the policy's cancellation 14 months prior to the accident.

The arbitrator concluded the applicant ought reasonably to have known the vehicle was uninsured and dismissed his claims for those benefits.

The applicant sought medical and rehabilitation benefits and income replacement benefits following a 1991 motor vehicle accident.

The insurer raised preliminary issues regarding limitation periods.

The arbitrator held that the applicant was precluded from claiming medical and rehabilitation benefits for services supplied beyond the 10-year anniversary of the accident, pursuant to section 6(3) of the Schedule.

The arbitrator also held that the claim for income replacement benefits was statute-barred because the application for mediation was filed more than two years after the insurer's clear and unequivocal refusal to pay benefits.

The applicant sought statutory accident benefits for caregiving, housekeeping, and medical rehabilitation following a motor vehicle accident.

The arbitrator dismissed the claims for caregiving and housekeeping benefits, finding the applicant's evidence lacked credibility and was inconsistent with his return to full-time work and school.

However, the arbitrator allowed the claim for medical and rehabilitation benefits in the amount of $5,067, finding that the chiropractic and massage treatments provided reasonable pain relief and assisted the applicant's functional improvement.

The applicant sought statutory accident benefits following a motor vehicle accident, including medical, attendant care, and housekeeping benefits.

At the hearing, the applicant's representative withdrew as she was unable to locate or receive instructions from the applicant.

The applicant did not appear at the hearing.

As the applicant bore the burden of proof and adduced no evidence, the arbitrator dismissed the application.

The applicant was ordered to pay $400 in costs to the insurer.

The applicant sought interim income replacement benefits following a motor vehicle accident.

In a supplementary decision, the arbitrator determined the quantum and effective date of the interim benefits.

After accounting for CPP deductions, the insurer conceded the applicant was entitled to the maximum enhanced benefit of $600 per week.

The arbitrator ordered the interim benefits to be payable effective March 20, 2007, the date the applicant first formally applied for them, rather than the date of the initial order or the date of termination.

No interest was awarded on the interim benefits.

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

The applicant failed to appear at the arbitration hearing and adduced no evidence to support the claim.

The arbitrator dismissed the application and awarded $400 in expenses to the insurer.

Following the settlement of a statutory accident benefits dispute, the parties were unable to agree on the quantum of expenses payable by the insurer.

The applicants sought $32,034.60 in fees and disbursements.

The insurer disputed the time claimed by a second lawyer retained for the hearing, the time claimed for correspondence, and the fees charged for expert reports.

The arbitrator found that retaining alternate counsel due to a scheduling conflict was reasonable and did not result in significant duplication of time.

The arbitrator also found the correspondence time and expert report fees to be reasonable, noting that the FSCO Professional Services Guideline rates do not strictly apply to medical-legal reports prepared for arbitration.

The applicants were awarded their full claimed expenses of $32,034.60.

The applicant, an Alberta resident insured under an Alberta policy, was injured in a motor vehicle accident in Ontario while a passenger in a friend's vehicle.

He applied for statutory accident benefits in Ontario.

The insurer brought a preliminary issue motion arguing that the Financial Services Commission of Ontario lacked jurisdiction.

The arbitrator agreed, finding that the Insurance Act only confers jurisdiction for automobile contracts formed in Ontario or for out-of-province contracts where the insured automobile was operated in Ontario.

Since neither scenario applied, the arbitration was dismissed for lack of jurisdiction.