OFSCDRS 2016

The applicant sought expenses following a successful arbitration and subsequent appeal regarding her entitlement to income replacement benefits and the applicable interest rate.

The arbitrator awarded the applicant her requested expenses of $3,559.50, noting her complete success on appeal and the insurer's late reinstatement of benefits which caused the applicant to incur legal expenses.

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

The parties disputed whether the applicant, who worked as a driving school instructor, was self-employed or an employee at the time of the accident.

The arbitrator found that the applicant was self-employed, as he engaged in his occupation as a sole proprietor, filed his taxes as such, and received payments inclusive of HST without employment deductions.

The clear definition of 'self-employed person' in section 3(1) of the Schedule was met, rendering traditional factual indicia tests unnecessary.

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

The Insurer approved initial treatment under the Minor Injury Guideline (MIG) but denied subsequent treatment plans, requesting the Applicant attend Insurer's Examinations (IEs) to determine if her injuries fell outside the MIG.

The Applicant refused to attend the IEs, arguing the Insurer failed to provide sufficient medical reasons in its notices.

The Arbitrator found that the Insurer's notices complied with the Schedule by stating it had reviewed the MIG and the treating practitioner's opinion and found no compelling evidence that the impairment was not predominantly a minor injury.

Because the Applicant failed to attend the mandatory IEs without a reasonable excuse, and given the substantial passage of time since the accident, she was precluded from proceeding to arbitration under section 55(2) of the Schedule.

The application was dismissed.

The applicant was injured in a motor vehicle accident and sought a determination of catastrophic impairment based on psychological injuries, along with income replacement benefits and medical benefits.

The arbitrator preferred the evidence of the applicant's psychological expert, finding she suffered a marked impairment in her ability to adapt, and declared her catastrophically impaired.

The claim for income replacement benefits was dismissed due to an unexplained four-year delay in re-electing benefits.

The requested medical benefits for physiotherapy and psychological treatment were approved as reasonable and necessary.

The applicant sought statutory accident benefits following a 2010 motor vehicle accident, claiming catastrophic impairment, attendant care, housekeeping, and non-earner benefits.

The insurer argued the applicant's impairments were solely due to pre-existing rheumatoid arthritis.

The arbitrator found the accident was a material contributing factor to the applicant's catastrophic impairment, relying on expert medical and psychological evidence.

However, the claims for attendant care and housekeeping benefits were dismissed because the applicant failed to provide documentary evidence that her service providers suffered an economic loss.

The claim for non-earner benefits was also dismissed due to insufficient evidence comparing pre- and post-accident activities.

The applicant was awarded $3,100 for the cost of examinations.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits, including a determination of catastrophic impairment, income replacement benefits, and medical benefits.

The arbitrator found that the applicant sustained a catastrophic impairment due to a marked impairment in the adaptation domain (deterioration or decompensation in a work-like setting) under the AMA Guides.

The applicant was awarded ongoing income replacement benefits of $400 per week, as she suffered a complete inability to engage in any employment for which she was reasonably suited.

Claims for various medical benefits and a special award were dismissed.

The applicant's request for an anonymity order was also denied.

The appellant, a pedestrian struck by a vehicle, appealed an Arbitrator's decision denying his claims for non-earner and housekeeping benefits.

He argued that the insurer's delay in denying the benefits created a presumption of entitlement, that hospital records should have been accepted as prima facie proof of causation, and that the Arbitrator misapplied the causation test.

The Director's Delegate dismissed the appeal, finding that the appellant was still required to prove entitlement despite any procedural breach by the insurer, that the hospital records were hearsay regarding causation, and that the Arbitrator correctly applied the causation tests.

Following the dismissal of TTC Insurance Company's appeal regarding the authority of the executrix to instruct counsel, the Estate of Francis Agius sought its legal expenses for the appeal.

The Director's Delegate found the Estate was entitled to its expenses based on its success.

The Delegate declined to fix arbitration expenses, as the arbitration was ongoing, but awarded the Estate $2,500 for the appeal expenses.

The insured applied for statutory accident benefits following a motor vehicle accident, seeking $126,673 for home modifications.

The insurer requested that the insured attend an orthopaedic examination to assess the claim.

The insured refused to attend, arguing the request was unreasonable and the notice was deficient.

The insurer brought a preliminary issue motion to preclude the insured from proceeding to arbitration.

The arbitrator found that the insurer's notice met all procedural requirements and that the requested examination was reasonably necessary to assess causation for the new benefit claimed.

The arbitration was adjourned until the insured attends the orthopaedic examination.

The insurer brought a motion to stay the arbitration proceedings until the insured attended in-person insurer examinations regarding catastrophic impairment.

The insured had delayed providing his responding medical reports for three years and then refused to attend further insurer examinations, arguing they were intrusive and unnecessary.

The arbitrator found that the insurer's request was reasonable and necessary given the passage of time and the overarching principle of procedural fairness.

The arbitration was stayed until the insured attends the examinations.

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

The insurer denied the claim.

On a preliminary issue hearing, the arbitrator considered whether the applicant was employed, self-employed, or receiving employment insurance at the time of the accident.

The applicant argued that monies received from the Ontario government's Second Career Program for dog grooming training constituted employment income or were analogous to employment insurance.

The arbitrator rejected these arguments, finding no statutory basis to expand the definitions.

The claim for income replacement benefits was dismissed.

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

The applicant continued to work for two years post-accident before claiming income replacement benefits.

The arbitrator found the applicant's testimony lacked credibility and noted numerous contradictions.

The arbitrator dismissed the claims, finding the applicant failed to comply with the notice requirements under section 32 of the Schedule and failed to prove a substantial inability to perform the essential tasks of his employment.

The claim for medical benefits was also dismissed as the treatment plan was not shown to be reasonable or necessary.

The applicant withdrew her application for arbitration for statutory accident benefits.

The insurer sought its expenses for the proceeding.

The arbitrator permitted the withdrawal and awarded the insurer $2,269.23 in expenses, finding that the applicant's failure to promptly inform the insurer of the withdrawal caused unnecessary preparation costs.

The insurer's claimed costs of over $11,000 were reduced as excessive and disproportionate.

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

A priority dispute between insurers was resolved, with Western Assurance assuming carriage of the claim.

State Farm brought a motion on consent to add Western Assurance as a party and remove itself from the arbitration.

The arbitrator granted the motion, finding jurisdiction under the Statutory Powers Procedure Act and the Dispute Resolution Practice Code to add and remove parties, and concluding that the proposed order was the most just, quickest, and least expensive manner of proceeding.

The insurer brought a motion to dismiss the applicant's application for arbitration for statutory accident benefits as frivolous under Rule 68 of the Dispute Resolution Practice Code.

The insurer had already paid attendant care benefits up to the non-catastrophic policy limit of $36,000.

The applicant sought to add the issue of catastrophic impairment, but the arbitrator found the applications for catastrophic determination were not submitted before the FSCO cut-off date to add issues.

The arbitrator dismissed the application for arbitration, finding no further attendant care benefits were payable and no basis for a special award.

No costs were awarded.

The applicant was injured in a motor vehicle accident and applied for arbitration after mediation failed.

The insurer made a Rule 76 offer to settle, which the applicant did not accept.

The applicant subsequently requested to withdraw his application prior to the hearing.

The insurer consented to the withdrawal on the condition that an expense hearing be held, seeking its costs of preparation.

The arbitrator found that the proceeding had not formally ended and retained jurisdiction to determine expenses.

Considering the consumer protection objectives of the legislation and the applicant's legitimate reasons for not accepting a full and final settlement, the arbitrator ordered that each party bear its own expenses and formally withdrew the application.

The applicant sought Income Replacement Benefits (IRBs) and medical benefits following a rear-end motor vehicle accident.

The insurer denied the claims, arguing the applicant did not suffer a substantial or complete inability to work and that the medical treatments were not reasonable and necessary.

The arbitrator found that the applicant continued to work for 14 months post-accident and that her subsequent medical complaints, including blackouts and incontinence, were not causally linked to the accident by the medical experts.

The arbitrator dismissed the application, concluding the applicant failed to prove entitlement to IRBs, medical benefits, or a special award.

The appellant, a minor, appealed an Arbitrator's decision ordering him to pay $3,172.50 in arbitration expenses to the respondent insurer after his application for arbitration was withdrawn.

The Director's Delegate allowed the appeal, finding that the Arbitrator failed to provide adequate reasons for the expense award, which constituted a breach of natural justice.

The Arbitrator had merely stated the parties' positions and a bald conclusion without explaining the basis for finding the expenses reasonable.

The decision was rescinded and the matter remitted for a rehearing before a different Arbitrator.

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

The insurer refused certain benefits, leading to arbitration.

A preliminary issue hearing was held to determine if the applicant had the mental capacity to proceed in the dispute resolution process, following a previous finding that he lacked capacity.

Based on a new capacity assessment report by an occupational therapist, which concluded the applicant could manage his affairs, and the arbitrator's own observations, the arbitrator found that the applicant now has the mental capacity to proceed.

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

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

The arbitrator proceeded in the applicant's absence pursuant to Rule 37.9 of the Dispute Resolution Practice Code.

As the applicant presented no evidence, the application was dismissed and the applicant was ordered to pay $500 in expenses to the insurer.