OFSCDRS 2017

The Applicant was injured in a motor vehicle accident and received Income Replacement Benefits (IRBs) until they were terminated by the Insurer.

The Applicant applied for arbitration six years after the termination, arguing the termination notice (OCF-9) was invalid because it directed her to contact an 'adjustor' while her file was handled by a 'claims representative'.

The Arbitrator found the notice was clear, unequivocal, and complied with the requirements set out in Smith v. Co-operators.

The Applicant's failure to dispute the termination within the two-year limitation period was not excused by the job title of the Insurer's employee.

The Applicant was held to be statute-barred from claiming IRBs, and the Insurer was awarded its expenses.

The applicant sought to withdraw her Application for Arbitration regarding statutory accident benefits after failing to attend an Insurer's Examination.

The insurer opposed the withdrawal, arguing the applicant should be statutorily barred from proceeding to arbitration or the Licence Appeal Tribunal.

The arbitrator permitted the withdrawal of the application on a without costs basis pursuant to Rule 70 of the Dispute Resolution Practice Code, finding no cogent evidence to deny the request made at the pre-hearing stage.

As the application was withdrawn, the issue of whether the applicant was precluded from proceeding to arbitration was moot.

No expenses were awarded.

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

The parties were unable to resolve their disputes through mediation, and the applicant applied for arbitration at the Financial Services Commission of Ontario.

At the hearing, the parties agreed on consent to dismiss the application for arbitration without costs.

The arbitrator ordered the application dismissed with no costs or expenses payable by either party.

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

After failing to attend multiple scheduled pre-hearing discussions, the applicant's representative sought to be removed from the record, and the insurer moved to dismiss the application.

The arbitrator found that the applicant had been given notice but chose not to participate, rendering the proceeding frivolous or vexatious.

The application was dismissed, the representative was removed, and the applicant was ordered to pay $500 in expenses to the insurer for needless delay.

The applicant sought statutory accident benefits following a motor vehicle accident but failed to attend the scheduled arbitration hearing.

The arbitrator proceeded in the applicant's absence and dismissed the application, as the applicant bore the onus of proving entitlement and presented no evidence.

The insurer was awarded $750 in expenses.

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

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

Prior to the hearing, the parties consented to the dismissal of the application for arbitration without costs.

The arbitrator dismissed the application and ordered no costs.

The appellant rescinded a 2005 full and final settlement of his accident benefits claims after a 2012 decision found the Settlement Disclosure Notice defective.

The insurer subsequently paid the claimed benefits with interest calculated from the date of rescission.

The appellant sought further interest from the dates the benefits originally became overdue, as well as a special award.

The Director's Delegate allowed the appeal in part, finding the Arbitrator erred in concluding that the appellant's conduct or the settlement itself constituted unusual circumstances precluding interest.

The Delegate ordered interest on housekeeping, caregiver, and non-earner benefits from the dates they became overdue, but denied further interest on attendant care and medical/rehabilitation benefits due to the lack of prior applications.

The issues of a special award and arbitration expenses were remitted for re-hearing.

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

The applicant's legal representatives brought a motion to withdraw due to a breakdown in the solicitor-client relationship, as they had been unable to reach the applicant for several months.

The applicant failed to attend the hearing despite receiving notice.

The arbitrator granted the motion to withdraw, dismissed the application for arbitration due to the applicant's failure to participate and prove his claims, and ordered the applicant to pay the insurer's expenses fixed at $1,000.

The insurer brought a motion to stay the applicant's arbitration hearing pending the completion of additional section 44 insurer's examinations.

The applicant sought a catastrophic impairment determination and submitted rebuttal reports to the insurer's initial assessments.

The insurer argued the rebuttal reports constituted a material change requiring further examinations.

The arbitrator found no material change, noting the differing opinions between occupational therapists did not evidence a declining or changed condition.

The motion for a stay was dismissed.

The respondent taxi driver was assaulted by a passenger, pushed, and slipped on ice while attempting to close the van door, resulting in a fractured leg.

The insurer appealed the arbitrator's decision that the incident constituted an 'accident' under the Statutory Accident Benefits Schedule.

The Director's Delegate dismissed the appeal, finding that the use or operation of the vehicle was a direct cause of the impairment and that the assault and slipping on ice were not intervening acts that broke the chain of causation.

The insurer brought a motion arguing that the applicant's claim for a non-earner benefit was statute-barred because he failed to apply for mediation within two years of the insurer's refusal to pay.

The arbitrator found that the applicant had not actually applied for the non-earner benefit when the insurer issued its initial denial in 2013.

Therefore, the insurer could not validly refuse a benefit that had not been claimed.

The limitation period did not begin to run until the insurer's subsequent denial in 2015, making the applicant's mediation request timely.

The motion was dismissed.

The Applicant sought to withdraw his Application for Arbitration for accident benefits at the outset of the scheduled three-day hearing.

The Insurer agreed to the withdrawal on a with-prejudice basis, provided it was awarded expenses.

The Arbitrator permitted the withdrawal on a with-prejudice basis and awarded the Insurer expenses for one day of hearing and two days of preparation, noting the late notice of withdrawal resulted in time thrown away.

The Applicant was ordered to pay the Insurer $4,535.23 in expenses and disbursements.

The appellant was injured in a motor vehicle accident and sought payment for an in-home assessment under the Statutory Accident Benefits Schedule.

The insurer failed to respond to the treatment plan within the required 10 business days.

The appellant argued this failure required the insurer to pay for the assessment regardless of its merits.

The Director's Delegate affirmed the Arbitrator's decision, holding that the mandatory payment provision was not raised at arbitration and, in any event, assessments remain subject to a reasonableness and necessity test.

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

The Insurer argued that a prior settlement was binding, but the Arbitrator found the Applicant's rescission letter valid despite lacking a fax cover page.

The Arbitrator declined to recuse himself after viewing the settlement documents.

The Applicant was precluded from arbitrating her claim for non-earner benefits because she failed to attend a mandatory section 44 medical examination.

The Arbitrator also found that the Applicant's injuries fell within the Minor Injury Guideline (MIG), as there was no compelling evidence linking her seizures to the accident, and multiple medical assessors concluded her injuries were minor.

Claims for a special award and interest were dismissed, and the Applicant was ordered to pay the Insurer's reasonable expenses.

The applicants sought accident benefits from the insurer following a motor vehicle accident.

The matter proceeded to an arbitration hearing.

Neither the applicants nor their representative attended the hearing, despite receiving notice and having a prior adjournment request denied.

The arbitrator proceeded in their absence and dismissed the applications for arbitration because the applicants failed to meet their burden of proof.

The arbitrator ordered the applicants to pay the insurer's expenses, finding their conduct in failing to pursue the applications and failing to notify the insurer of their non-attendance unnecessarily lengthened the proceeding.

The insurer brought a preliminary issue motion arguing that the applicant's claim for non-earner benefits was statute-barred because she failed to apply for arbitration within two years of a clear and unequivocal denial.

The arbitrator found that the insurer's initial denial was premature and rendered ambiguous by subsequent contradictory communications and requests for further medical information.

The limitation period did not begin to run until a later, unequivocal denial was issued.

The motion was dismissed, and the claim was allowed to proceed.

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

After the applicant's representative was removed from the record, the applicant failed to attend the scheduled arbitration hearing despite receiving notice.

The insurer brought a motion to dismiss the application for non-attendance.

The arbitrator granted the motion, dismissing the application and ordering the applicant to pay $1,400 in expenses to the insurer.

The insured was injured in a motor vehicle accident and received income replacement benefits until the insurer terminated them following insurer examinations.

The insurer sent multiple Explanations of Benefits (OCF-9s) advising of the termination and the dispute resolution process.

The insured applied for arbitration after the 90-day limitation period following mediation had expired, arguing the refusals were not clear and unequivocal.

The Director's Delegate allowed the insurer's appeal, finding that the OCF-9s, both individually and in totality, met the requirements for a valid refusal by clearly denying benefits and explaining the dispute resolution process.

The insured's application for arbitration was dismissed as statute-barred.

The appellant, an Ontario resident, was injured when he fell off an ATV in British Columbia.

The ATV was owned by a BC resident and was not insured or required to be insured in BC.

The appellant claimed statutory accident benefits under his Ontario automobile policy, arguing the ATV should be considered an automobile under Ontario law.

The Director's Delegate dismissed the appeal, applying the territoriality principle to find that Ontario law regarding mandatory insurance does not apply to a vehicle owned and operated in British Columbia.

Therefore, the ATV did not meet the extended definition of an automobile, and the appellant was not involved in an 'accident' under the Statutory Accident Benefits Schedule.

The applicant was injured in a motor vehicle accident and sought a determination that he was catastrophically impaired under the Statutory Accident Benefits Schedule.

The arbitrator considered whether the applicant suffered a marked or extreme impairment due to a mental or behavioural disorder, or a whole person impairment of 55 percent or more.

The arbitrator preferred the evidence of the insurer's experts, finding that the applicant's mental and behavioural impairments were mild to moderate.

Combining the physical and psychological impairments, the arbitrator determined the applicant's whole person impairment was 31 percent.

The application for a catastrophic impairment determination was dismissed.