OFSCDRS 2014

The applicant was injured when struck by a piece of airborne scrap metal while waiting in his truck.

He applied for statutory accident benefits.

The insurer initially investigated whether the incident met the definition of an 'accident' under the Schedule.

After several months, the insurer issued an OCF-9 stating its investigation was complete and it was accepting the claim.

A year later, the insurer attempted to terminate benefits, arguing the incident was not an accident.

The arbitrator held that the insurer had expressly and unequivocally waived its right to dispute the 'accident' issue when it confirmed the completion of its investigation and accepted the claim.

The applicant's representative brought a motion to be removed as representative of record because the applicant could not be located.

The arbitrator granted the motion to withdraw.

As the applicant did not attend the hearing and no evidence was submitted in support of her claim for a non-earner benefit, the application for arbitration was dismissed with $500 in costs payable to the insurer.

The Appellant appealed an Arbitrator's preliminary decision finding that he was not involved in a motor vehicle accident as defined by the Statutory Accident Benefits Schedule.

The Arbitrator had concluded, based on witness testimony and credibility assessments, that the Appellant was not in the parked van when it was struck by another vehicle.

On appeal, the Director's Delegate held that the Arbitrator's findings were reasonably inferred from the evidence and did not constitute an error of law.

The appeal was dismissed and the Arbitrator's decision confirmed.

The applicant applied for statutory accident benefits, claiming he was injured when the car he was a passenger in was rear-ended.

The insurer denied further benefits and sought repayment of paid benefits, alleging the accident was staged.

The arbitrator accepted expert collision reconstruction evidence that the vehicle damage was inconsistent with a rear-end collision and instead consistent with striking a pole.

Finding that the reported accident did not occur, the arbitrator dismissed the application and ordered the applicant to repay $5,971.83 in benefits due to wilful misrepresentation, along with $4,937.77 in arbitration expenses.

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

The arbitration hearing was scheduled but the applicants failed to attend on two occasions without providing a reason.

The arbitrator dismissed the applications for arbitration due to the applicants' failure to present evidence.

The insurer sought expenses, including a claim that the applicants' paralegal representative be held personally liable.

The arbitrator awarded the insurer $2,000 in expenses payable by the applicants, but found no grounds to hold the representative personally liable.

The representative's motion to be removed from the record due to a breakdown in the solicitor-client relationship was granted.

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

After productions revealed the applicant had been involved in a subsequent accident and received income replacement benefits from another insurer—inconsistent with his claims in this arbitration—his representatives, Pace Law Firm, brought a motion to be removed from the record.

The applicant failed to attend the hearing.

The arbitrator granted the motion to remove Pace Law Firm due to a breakdown in the solicitor-client relationship.

As the applicant presented no evidence to support his claims, the arbitration was dismissed.

The insurer was awarded $1,500 in expenses.

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

After failing to attend two scheduled pre-hearings without explanation, the insurer sought to dismiss the proceeding.

The arbitrator found that the applicant and her representative were given proper notice of all proceedings as required by the Dispute Resolution Practice Code.

As the applicant bore the burden of proving entitlement to benefits and provided no evidence, the application for arbitration was dismissed.

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

After the applicant's legal counsel withdrew, the applicant failed to attend a motion and two scheduled pre-hearings without explanation.

The insurer sought dismissal of the proceeding.

The arbitrator dismissed the application for arbitration pursuant to Rule 68 of the Dispute Resolution Practice Code due to the applicant's failure to attend and failure to provide evidence supporting his claims.

The applicant was injured in a motor vehicle accident and applied for weekly caregiver benefits, claiming he was the primary caregiver for his two young children.

The insurer denied the claim.

At arbitration, the evidence showed that while the applicant was an involved father, he worked full-time in a limousine business, whereas his wife was a full-time homemaker who handled the majority of day-to-day childcare tasks.

The arbitrator concluded that the applicant's wife, not the applicant, was the primary caregiver at the time of the accident.

As caregiver benefits are only available to the primary caregiver, the application was dismissed.

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

After their legal representative withdrew due to a breakdown in the relationship, the applicants failed to attend a pre-hearing discussion and the scheduled arbitration hearing.

The arbitrator proceeded in their absence and dismissed their claims for failing to present evidence to establish entitlement.

Each applicant was ordered to pay $500 toward the insurer's arbitration expenses.

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

The insurer denied the benefits, arguing the treatments were not reasonable, necessary, or actually incurred.

The arbitrator dismissed the applicant's claims in their entirety, finding her testimony lacked credibility and was inconsistent with the clinical notes of her regular treating physicians.

The arbitrator drew adverse inferences from the applicant's failure to call treating practitioners or her son, who allegedly provided care, and concluded the claimed services were either not provided or not reasonably required.

The appellant sought to appeal an arbitrator's preliminary order denying his request for interim legal expenses to fund a rebuttal catastrophic impairment assessment.

The arbitrator had found that while the appellant met the test for interim legal expenses, the $50,000 limit on medical and rehabilitation benefits under section 18 of the 2010 Schedule precluded the award.

The Director's Delegate exercised discretion to accept the appeal, finding that it raised a novel and broadly important issue of whether the statutory benefit maximums apply to interim expense awards under the Insurance Act.

The Insurer raised a preliminary issue that the Applicant was statute-barred from claiming housekeeping and home maintenance benefits, while the Applicant brought a motion for interim income replacement benefits.

The Arbitrator found that the Insurer's refusal to pay housekeeping benefits was clear and unequivocal, triggering the two-year limitation period under s. 281.1(1) of the Insurance Act, which the Applicant missed.

On the motion for interim benefits, the Arbitrator held that despite the Insurer's breach of s. 37 of the SABS in terminating income replacement benefits, interim benefits are a discretionary remedy.

Given the Applicant's unexplained five-year delay in challenging the termination and lack of evidence of urgent financial need, the motion for interim benefits was dismissed.

The applicant sought statutory accident benefits following a motor vehicle accident but failed to attend the pre-hearing and preliminary issue hearing.

Her representative had previously been removed from the record due to loss of contact.

The insurer brought a motion to dismiss the arbitration.

The arbitrator found that the applicant had abandoned her claim and dismissed the application under Rule 68 of the Dispute Resolution Practice Code, awarding $200 in costs to the insurer.

The applicant sought to proceed to arbitration for income replacement benefits and housekeeping and home maintenance benefits after the two-year limitation period had expired.

She argued the limitation period should be tolled because she lacked capacity to instruct counsel due to severe substance abuse and cognitive impairments.

The arbitrator found the applicant was an unreliable historian and failed to rebut the presumption of capacity, precluding her claim for housekeeping benefits.

However, the arbitrator found the insurer's notices terminating income replacement benefits were confusing and not clear and unequivocal, particularly given the applicant's extremely low cognitive abilities.

Therefore, the limitation period for the income replacement benefits claim did not commence, and the applicant was permitted to proceed to arbitration on that issue.

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

The matter proceeded to an arbitration hearing, but the applicant failed to attend.

At the hearing, the applicant's representative brought an unopposed motion to be removed from the record, which was granted.

Due to the applicant's failure to attend and prove her claim, the arbitrator dismissed the application for arbitration.

No order was made regarding expenses, though the arbitrator remained seized of the issue.

The applicant sought attendant care and medical benefits following a motor vehicle accident.

The arbitrator dismissed the claims, finding that the applicant failed to provide sufficient evidence of significant injuries or a need for attendant care.

The applicant's own prior statements contradicted his claim for attendant care, and he failed to introduce a valid Form 1 or the disputed treatment plan into evidence.

The Applicant was injured in a motor vehicle accident and sought payment for nine treatment plans totaling $12,085.66 from Osler Rehabilitation Centre.

The Insurer denied the claims.

At arbitration, the Arbitrator found the Applicant failed to meet her burden of proof that the medical benefits claimed were reasonable and necessary.

The Arbitrator concluded that the invoices and treatment plans from the rehabilitation centre were highly unreliable, containing numerous inconsistencies regarding the type, frequency, and providers of the treatment allegedly received.

The claims for medical benefits, interest, and a special award were dismissed.

The applicant applied for arbitration concerning her entitlement to statutory accident benefits following a motor vehicle accident.

Her counsel previously withdrew from the record after losing contact with her.

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

The arbitrator dismissed the application as vexatious due to the applicant's failure to provide evidence or attend, and ordered the applicant to pay the insurer's expenses fixed at $750.

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

The insurer subsequently requested an examination under oath, which the applicant attended but refused to answer questions regarding those specific benefits.

The insurer then terminated the benefits.

In this preliminary issue hearing, the arbitrator held that the insurer was precluded from conducting the examination under oath regarding those benefits because it failed to request the examination within 10 business days of receiving the application and disability certificate, as required by s. 36(4)(c) of the Statutory Accident Benefits Schedule.

Consequently, the insurer was not entitled to suspend the benefits under s. 33(6).

The applicant was awarded expenses for the hearing.