OFSCDRS 2013

The applicant sought a determination that she sustained a catastrophic impairment as a result of a 1999 motor vehicle accident.

The matter was referred back by the Director's Delegate for clarification on the whole person impairment (WPI) rating for 13 specific impairments identified by the applicant's assessor.

The Arbitrator found that the applicant's impairments, including her primary complaints of a lumbar spine discectomy and chronic pain, were not caused by the accident, resulting in a 0% WPI rating.

Even assuming causation, the Arbitrator calculated the WPI at 41%, which falls short of the 55% threshold required for a catastrophic impairment designation.

The Applicant was injured in a motor vehicle accident and applied for a determination of catastrophic impairment.

The parties agreed on a 34% physical whole person impairment but disputed the mental and behavioural impairment rating.

The arbitrator preferred the evidence of the Applicant's psychological expert, finding that the Applicant suffered a marked impairment in adaptation to work environments due to severe panic disorder and agoraphobia.

The arbitrator concluded that the Applicant sustained a catastrophic impairment under both clause 2(1.2)(g) (marked mental impairment) and clause 2(1.2)(f) (combined physical and mental impairment of 60%).

The applicant was injured in a motor vehicle accident and applied for statutory accident benefits, which were denied by the insurer.

The applicant failed to attend the preliminary issue hearing, as well as previous proceedings, and her previous counsel had been removed from the record.

The arbitrator dismissed the application for arbitration due to the applicant's failure to meet her onus to establish entitlement to the claims.

The insurer was awarded its reasonable expenses fixed at $3,150.40.

The applicant was injured in a motor vehicle accident and received caregiver benefits from her insurer.

The insurer terminated the benefits after 104 weeks, arguing she no longer met the test of suffering a complete inability to carry on a normal life.

The arbitrator found that the applicant's physical injuries, combined with chronic pain and a diagnosed Somatoform Pain Disorder, continuously prevented her from engaging in substantially all of her pre-accident activities.

The arbitrator ordered the insurer to pay ongoing caregiver benefits but declined to order a special award, finding the insurer's denial was not unreasonable given the complex medical evidence.

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

After disputes arose, the applicant applied for arbitration but failed to participate in the process or attend the hearing despite proper notice.

As the applicant bore the onus of proving entitlement and presented no evidence, the arbitrator dismissed the arbitration.

The applicant failed to attend his scheduled arbitration hearing for statutory accident benefits.

At the hearing, the applicant's counsel successfully moved to be removed from the record due to a breakdown in the solicitor-client relationship.

The arbitrator then proceeded in the applicant's absence pursuant to the Statutory Powers Procedure Act and the Dispute Resolution Practice Code.

As the applicant presented no evidence to prove his claims, the application for arbitration was dismissed.

The Applicant sought statutory accident benefits following two motor vehicle accidents in November 2009.

He claimed entitlement to housekeeping and home maintenance services, attendant care benefits, income replacement benefits, and various assessment expenses.

The arbitrator dismissed all claims, finding the Applicant's testimony lacked credibility and corroboration.

The arbitrator concluded the Applicant's impairment was a Grade II whiplash-associated disorder falling within the Pre-approved Framework Guideline, precluding attendant care benefits and limiting income replacement benefits.

Furthermore, the Applicant failed to provide reasonably required employment information, barring his claim for income replacement benefits under section 33 of the SABS.

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

The insurer denied claims for attendant care, caregiver, and housekeeping benefits, arguing the applicant's injuries were minor and her presentation was not credible.

The arbitrator found that the applicant suffered significant psycho-emotional injuries, including chronic pain syndrome and post-traumatic stress disorder, resulting in a catastrophic impairment.

The arbitrator awarded attendant care benefits at the maximum rate of $6,000 per month, caregiver benefits for her younger son, and housekeeping benefits.

A claim for home modifications was denied as the renovations were planned prior to the accident.

The arbitrator also ordered a 10% special award against the insurer for unreasonably withholding payments without adequately assessing the medical evidence.

The cross-appellant was injured in a motor vehicle accident and sought income replacement benefits (IRBs).

The insurer terminated the IRBs and the cross-appellant applied for mediation.

The arbitrator initially found the claim was not statute-barred, but on appeal, the Director's Delegate found the arbitrator erred in law by failing to determine whether the insurer's refusal was clear and unequivocal.

On cross-appeal, the Director's Delegate held that the insurer's Explanation of Benefits (OCF-9) provided conditional and ambiguous statements regarding the right to a rebuttal examination and the limitation period.

Because the refusal was not clear and unequivocal, the two-year limitation period was never triggered, and the cross-appellant was permitted to proceed to arbitration on the IRB claim.

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

The insurer terminated housekeeping and income replacement benefits.

The arbitrator held that the appellant was precluded from proceeding to arbitration due to the expiration of the limitation period.

On appeal, the Director's Delegate found that the arbitrator erred in law by failing to give reasons for the housekeeping limitation order.

Furthermore, the Delegate held that the insurer could not rely on the limitation period for the income replacement benefits because it failed to comply with the mandatory statutory termination process, specifically by not providing the required medical examination reports to the appellant and her health practitioner.

The arbitrator's decision was rescinded, and the issues were returned to arbitration.

The insurer brought a motion to stay the arbitration pending the insured's attendance at further catastrophic impairment assessments.

The insured had initially claimed catastrophic impairment under Criterion 8 (mental or behavioural disorder), but later obtained reports indicating she also met Criterion 7 (55% whole person impairment).

The insurer sought to have her assessed under Criterion 7.

The arbitrator applied the six-part test for determining whether an insurer's request for an examination is reasonable and necessary.

Finding that the insurer would be prejudiced if not permitted to investigate the new claim, the arbitrator granted the motion and adjourned the hearing pending the insured's attendance at the requested assessments.

The appellant insurer sought to appeal an arbitrator's preliminary order staying the arbitration after the arbitrator found the self-represented respondent lacked the mental capacity to proceed.

The Director's Delegate accepted the appeal at this time, restricted to the issue of whether the arbitrator erred in law in the procedure followed to determine the respondent's mental capacity.

The Delegate found strength in the insurer's argument that the procedure may have lacked fairness, as there was no formal notice of a capacity hearing and the determination was made without medical evidence.

The Delegate also admitted correspondence between the arbitrator and the Public Guardian and Trustee as fresh evidence.

Following an arbitration where the applicant's claims for statutory accident benefits were dismissed, the insurer sought its expenses.

The arbitrator found that the insurer was completely successful and that the applicant's conduct, including failing to comply with disclosure requirements and giving inconsistent histories to medical providers, unnecessarily prolonged the hearing.

The arbitrator awarded the insurer its expenses but reduced the requested hourly rate for counsel from $150.00 to $117.85, as the higher rate is only available to insured persons under the Dispute Resolution Practice Code.

The insurer was awarded $8,555.86 in fees, inclusive of HST, with no award for disbursements.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for an orthopaedic mattress and retraining expenses.

The insurer denied the claims because the applicant incurred the expenses before submitting a treatment plan, contrary to section 38(1.1) of the Statutory Accident Benefits Schedule.

The applicant argued for relief from forfeiture under section 129 of the Insurance Act and section 31 of the Schedule.

The arbitrator held that the insurer was not liable to pay for the expenses because the treatment plans were not submitted prior to the expenses being incurred.

The arbitrator also found that section 129 of the Insurance Act and section 31 of the Schedule did not apply to relieve the applicant from the requirement to submit a treatment plan before incurring an expense.

The application was dismissed.

The applicant was injured in a motor vehicle accident and applied for statutory accident benefits, including caregiving, attendant care, and housekeeping.

The insurer scheduled section 42 insurer's examinations to assess her ongoing entitlement.

The applicant refused to attend, stating she was exhausted and felt she would not meet the disability tests.

The insurer suspended her benefits.

In a preliminary issue hearing, the arbitrator found that the applicant failed to attend the scheduled examinations without a reasonable explanation.

Consequently, the applicant is precluded from seeking entitlement to those benefits during the period of non-compliance.

The applicant failed to attend the scheduled hearing for her accident benefits claims.

Her counsel brought a motion to be removed from the record, citing a breakdown in the solicitor-client relationship due to an inability to contact the applicant.

The arbitrator granted the motion to remove counsel.

The insurer sought dismissal of the arbitration and expenses.

Noting that the applicant had never appeared at the Commission despite multiple scheduled pre-hearings, the arbitrator dismissed the application for arbitration and ordered the applicant to pay $2,000 in expenses to the insurer.

The insurer appealed an arbitrator's preliminary decision that the insured's medical and rehabilitation claim was not subject to the $3,500 limit under the Minor Injury Guideline (MIG).

The Director's Delegate allowed the appeal, finding that the arbitrator erred by failing to apply the correct test of whether the impairment was predominantly a minor injury, improperly shifting the burden of proof to the insurer, and incorrectly concluding that the MIG was non-binding.

Furthermore, the arbitrator breached procedural fairness by conducting independent research and relying on legal arguments without giving the parties an opportunity to respond.

The decision was rescinded and the matter remitted for a full hearing before a different arbitrator.

The Applicant sought production of the Insurer's complete accident benefits file from the date of the collision to the date of the hearing.

The Insurer claimed it had produced the entire file, subject to privilege and relevance.

The Arbitrator found extraordinary circumstances justifying an order for an Affidavit of Documents, noting missing documentation, two file numbers, and the Insurer's blanket claims of privilege.

The Arbitrator ordered the Insurer to produce the file up to the date litigation privilege attached, provide an Affidavit of Documents, and awarded expenses of the motion to the Applicant.

The applicants sought accident benefits following a motor vehicle accident, claiming that Ms. Hoey was driving the vehicle.

The insurer terminated benefits, alleging that Mr. Vera, whose license was suspended, was actually driving and that the applicants wilfully misrepresented this material fact.

Following a preliminary issue hearing, the arbitrator found that the preponderance of evidence, including independent witness testimony and Mr. Vera's actions at the scene, established that Mr. Vera was the driver.

The arbitrator concluded that both applicants wilfully misrepresented material facts, disentitling them to benefits, and awarded the insurer its reasonable expenses.

The applicant was injured in a motor vehicle accident and applied for arbitration of her claims for statutory accident benefits.

The parties settled the claims on the eve of the hearing, with the insurer agreeing to pay the applicant's arbitration expenses.

The parties could not agree on the amount, leading to this hearing.

The arbitrator reduced the claimed legal fees, finding 50 hours reasonable instead of the claimed 62.625 hours, and deducted a small amount for parking and mileage from the disbursements.

The applicant was awarded $18,385.66 in fees and disbursements.