OFSCDRS 2014

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

After participating in early stages of the proceeding, the applicant failed to attend the resumed pre-hearing and the scheduled arbitration hearing.

The insurer requested an order dismissing the application.

The arbitrator dismissed the application for arbitration due to the applicant's failure to participate.

The appellant appealed an arbitrator's decision denying her claims for caregiver and non-earner benefits following a motor vehicle accident.

The Director's Delegate found no error of law in the arbitrator's weighing of the medical evidence, which preferred the insurer's assessments over the appellant's experts.

The Director's Delegate also rejected the argument that the arbitrator erred by allowing the appellant to proceed unrepresented, noting there was a presumption of capacity and no signs of mental difficulty that would require an inquiry under the Substitute Decisions Act.

The appeal was dismissed.

The applicant was struck on the head by a parking garage control arm while walking into the garage behind a car.

He applied for statutory accident benefits, but the insurer denied the claim, arguing the incident was not an 'accident' under section 2(1) of the Schedule.

The arbitrator found that the car entering the garage triggered the arm to lift and lower, satisfying both the purpose and causation tests.

The arbitrator concluded that the use or operation of the car directly caused the injury, and therefore the applicant was injured in an 'accident'.

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

After failing to attend a pre-hearing discussion, the matter was scheduled for an arbitration hearing.

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

The arbitrator dismissed the application for arbitration due to the applicant's failure to participate and tender evidence.

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

The Appellant was injured in a motorcycle accident and sought ongoing post-104 week income replacement benefits (IRBs) and a special award from his insurer.

The Arbitrator awarded IRBs for a limited period and denied the special award.

On appeal, the Appellant argued he was entitled to ongoing IRBs due to the insurer's procedural non-compliance with termination requirements and that he met the post-104 week disability test.

The Director's Delegate dismissed the IRB appeal, finding no error of law and affirming that procedural errors do not grant benefits in perpetuity.

However, the Delegate rescinded the denial of the special award, finding the Arbitrator failed to provide adequate reasons addressing whether the insurer's continued refusal to pay IRBs was reasonable in light of new medical evidence provided.

The special award issue was remitted for redetermination.

The insurer sought an order requiring the applicant to attend a further psychiatric insurer examination to determine catastrophic impairment, as the psychiatrist who conducted the initial examination had died.

The applicant agreed to attend on the condition that the insurer fund a rebuttal assessment without a $2,000 limit.

The arbitrator found that a further examination was reasonably required in the interest of fairness.

The arbitrator also ordered the insurer to fund a rebuttal assessment without a $2,000 limit, as the applicant's right to a rebuttal assessment crystallized under the Schedule in effect at the time of the 2007 accident.

Following the dismissal of the applicant's claims in an arbitration proceeding, the insurer sought its expenses.

The arbitrator found the insurer was completely successful and entitled to its expenses.

The insurer claimed $16,587.10, but the arbitrator found the hours claimed excessive for a simple two-day hearing with only two witnesses.

Applying Legal Aid rates and a 1:1 preparation-to-hearing ratio, the arbitrator fixed the insurer's expenses at $5,300.00, inclusive of fees, disbursements, and taxes.

The applicant sought a determination that she was catastrophically impaired following a motor vehicle accident, claiming marked or extreme impairment due to a mental or behavioural disorder, or alternatively, a 55% or more whole person impairment (WPI).

The arbitrator found that the applicant did not suffer a marked or extreme mental or behavioural impairment.

After evaluating conflicting medical evidence regarding her physical and cognitive injuries, the arbitrator assessed her combined WPI at 28%, well below the 55% threshold.

The applicant was awarded $6,000 for the costs of catastrophic assessments, but her claims for attendant care benefits were dismissed.

The insurer was awarded its arbitration expenses.

The insurer appealed an Arbitrator's decision finding that the claimant suffered a catastrophic impairment due to a mental or behavioural disorder and awarding ongoing attendant care and housekeeping benefits.

The Director's Delegate allowed the appeal, finding that the Arbitrator failed to give adequate reasons, reversed the burden of proof, and failed to fairly consider the evidence.

The medical evidence presented by the claimant did not address the criteria under the AMA Guides, and her uncorroborated evidence was insufficient to prove catastrophic impairment.

The Arbitrator's orders were revoked, and the claimant was ordered to repay interim benefits.

The appellant insurer appealed an arbitrator's preliminary decision regarding the quantum of attendant care benefits payable to the respondent insured.

The insurer argued that the quantum should be limited to the amount actually paid to the professional care provider, rather than the higher amount assessed in the Form 1.

The Director's Delegate dismissed the appeal, confirming that under the 2010 Statutory Accident Benefits Schedule, once the entitlement threshold of an 'incurred' expense is met, the quantum of the benefit is determined in accordance with the Form 1, subject to statutory maximums, and is not strictly limited to the actual economic loss or amount paid to the provider.

The applicant, who was injured in a motor vehicle accident, sought an interim order requiring the insurer to fund a rebuttal catastrophic impairment assessment.

The insurer had already paid the $50,000 maximum in medical and rehabilitation benefits for non-catastrophic injuries.

The arbitrator found that while the applicant met the criteria for an interim expense award—raising a bona fide issue, demonstrating the expense was reasonable and necessary, and showing financial inability to pay—the request was barred by the statutory limits.

Because the cost of assessments is included in the medical and rehabilitation benefits limit under the Schedule, the arbitrator could not order the insurer to exceed the $50,000 cap.

The motion was dismissed with no order as to expenses.

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

The application was dismissed after the applicant failed to attend the pre-hearing discussion and the arbitration hearing.

The insurer sought its expenses for the arbitration.

The arbitrator awarded the insurer $750.00 in expenses, inclusive of all fees, disbursements, and taxes, noting the insurer's complete success and the applicant's failure to present evidence or submissions.

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

The parties were unable to resolve their disputes through mediation, and the applicant applied for arbitration.

At the scheduled arbitration hearing, the applicant failed to attend or provide any evidence to support her claim.

The arbitrator dismissed the application and ordered the applicant to pay the insurer's expenses in the amount of $750.00.

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

The application was previously dismissed after the applicant failed to attend the pre-hearing discussion and the arbitration hearing.

In this decision on expenses, the arbitrator awarded the insurer $750.00 in costs, inclusive of all fees, disbursements, and taxes, as the insurer attended and was entirely successful.

Following the dismissal of the applicant's claim for statutory accident benefits due to her failure to attend the pre-hearing discussion and arbitration hearing, the insurer sought its expenses.

The arbitrator awarded the insurer $750.00 in expenses, inclusive of all fees, disbursements, and taxes, noting that the insurer was entirely successful and the applicant made no submissions.

The applicant was injured in a motor vehicle accident and subsequently pled guilty to dangerous driving causing bodily harm, receiving a conditional discharge.

The insurer denied income replacement and housekeeping benefits, arguing the applicant was excluded under section 30 of the Statutory Accident Benefits Schedule.

The arbitrator found that while the applicant was not 'convicted' of a criminal offence under subsection 30(2) due to the conditional discharge, he was 'found guilty' under subsection 30(4).

Consequently, the applicant was precluded from receiving benefits from the date of the accident until the date of his conditional discharge, and any benefits held in trust for that period were to be returned to the insurer.

However, he was not precluded from receiving benefits after the charge was finally disposed of.

The applicant was injured in a motor vehicle accident in 2008 and sought ongoing income replacement benefits, housekeeping benefits, and medical benefits for psychological treatment.

The insurer terminated benefits, relying on surveillance evidence and medical assessments indicating the applicant's condition had improved and he was exaggerating symptoms.

The arbitrator found the applicant's evidence lacked credibility, noting he failed to disclose a subsequent 2010 accident to assessors and attributed impairments from the second accident to the first.

The application for arbitration was dismissed, as the applicant failed to prove a complete inability to engage in suitable employment or a substantial inability to perform housekeeping tasks.

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

The parties disputed the hourly rate for attendant care benefits and whether the applicant was precluded from claiming housekeeping benefits due to a limitation period.

The arbitrator held that the rate for attendant care benefits is determined by the prevailing Form 1 under the Schedule, not the minimum wage under the Employment Standards Act.

The arbitrator also held that the applicant was precluded from arbitrating the housekeeping benefits claim because he failed to apply for mediation within two years of the insurer's clear and unequivocal denial.

The applicant was injured in a motor vehicle accident and applied for arbitration at the Financial Services Commission of Ontario after a dispute with the insurer over accident benefits.

The applicant failed to communicate with his counsel or attend the pre-hearing and hearing.

At the hearing, the applicant's counsel successfully moved to withdraw from the record.

The insurer moved to dismiss the application due to the applicant's failure to participate.

The arbitrator dismissed the application in its entirety and awarded the insurer $495 in expenses for counsel fees, rescinding an initial award for the arbitration filing fee.

The applicants applied for statutory accident benefits following a motor vehicle accident and subsequently filed for arbitration when the insurer denied certain benefits.

The applicants failed to appear for any proceedings, and their counsel withdrew from the record after losing contact with them.

The insurer brought a motion to dismiss the applications for arbitration and sought its expenses.

The arbitrator granted the motion, dismissing the applications due to the applicants' failure to pursue their claims, and ordered the applicants to pay the insurer's legal expenses.