Administrative Law - OFSCDRS

The appellant insurer appealed an interim arbitration decision, arguing that the arbitrator should not continue to conduct the hearing due to a reasonable apprehension of bias.

The Director's Delegate allowed the appeal to proceed solely on the issue of whether the arbitrator could continue.

The Director's Delegate found that the combination of procedural confusion, the rulings made by the arbitrator, and the contentious nature of the preliminary hearing established a reasonable apprehension of bias.

The appeal was allowed, and it was ordered that the arbitration hearing must be conducted by a different arbitrator.

The insurer appealed an arbitration decision awarding the respondent additional weekly income benefits and a special award.

The insurer argued the arbitrator erred in law by admitting oral testimony from the respondent's medical expert that went beyond his written reports, causing unfair surprise.

The Director's Delegate dismissed the appeal, finding that the expert's testimony regarding the respondent's medication and physical limitations was a reasonable amplification of his reports and the medical record.

Furthermore, the insurer's counsel did not object to the testimony at the hearing, chose to cross-examine the expert, and did not request an adjournment to call responding evidence, thereby waiving the right to claim procedural unfairness.

The appellant appealed an arbitrator's decision regarding the calculation of weekly income benefits under the Statutory Accident Benefits Schedule.

The appellant argued that his income should be averaged only over the 33 weeks he actually worked in the 52 weeks preceding the accident, rather than the full 52 weeks.

He also argued that the arbitrator erred by not following a previous appellate decision, raising the issue of whether stare decisis applies to the tribunal.

The Director of Arbitrations held that appellate decisions of the Director are binding on first-instance arbitrators.

However, the Director agreed with the arbitrator's interpretation of the Schedule, finding that the gross weekly income must be averaged over the full 52 weeks, regardless of periods of unemployment.

The appeal was dismissed.

The applicant was injured in a motor vehicle accident and applied for statutory accident benefits from Wawanesa, who denied coverage alleging the policy was void due to misrepresentation and had been terminated prior to the accident.

The applicant then applied to Guarantee, the insurer of the other vehicle, who argued Wawanesa was responsible.

The arbitrator held that Ontario Regulation 283/95 did not apply retroactively to this dispute.

The arbitrator further found that Wawanesa failed to properly terminate the policy because the premium refund did not accompany the notice of termination as required by statutory condition 12 of the Insurance Act.

Additionally, the applicant's misrepresentations did not render the policy void ab initio for the purpose of statutory accident benefits.

Wawanesa was ordered to pay the benefits.

The applicant was injured in a motor vehicle accident and received rehabilitation assistance from Trauma Services.

A dispute arose over the outstanding account, and an application for arbitration was filed.

The insurer raised a preliminary issue, arguing that the Commission lacked jurisdiction because the arbitration was actually brought by Trauma Services rather than the insured person.

The Arbitrator found that the applicant had authorized Trauma Services to access the mediation and arbitration processes on her behalf, and that she had properly retained counsel to proceed with the application.

The Arbitrator concluded that the arbitration was properly instituted by the applicant and that the Commission had jurisdiction to hear the matter.

The insurer appealed two arbitration decisions regarding statutory accident benefits.

The insurer argued it should be allowed to set off an overpayment of benefits against future payments, and that it should be allowed to deduct post-accident income the insured reported from her husband's business.

The Director's Delegate dismissed these grounds, finding the insured did not materially contribute to the overpayment and the reported income was merely for income splitting.

However, the Director's Delegate allowed the appeal regarding a special award ordered against the insurer, finding that the arbitrator breached procedural fairness by raising the issue in her decision without giving the insurer a reasonable opportunity to present evidence in response.

The special award was revoked and a partial rehearing was ordered.

The appellant appealed an arbitrator's decision denying him continued weekly income benefits following a motor vehicle accident.

The appellant alleged that the arbitrator demonstrated bias against him and erred in excluding two psychiatric reports submitted late in the hearing.

The Director of Arbitrations found no reasonable apprehension of bias, noting the arbitrator accommodated the unrepresented appellant and conducted the hearing fairly.

The Director also upheld the exclusion of the late medical reports due to lack of timely notice to the insurer.

The arbitrator's findings that the appellant lacked credibility and was not disabled from performing his essential tasks were supported by the evidence.

The appeal was dismissed.

The Applicant sought to withdraw his Application for Arbitration for statutory accident benefits after realizing he had missed the two-year limitation period, intending instead to pursue a court action against his former solicitor for negligence and an alternate claim for benefits.

The Arbitrator permitted the withdrawal but found that commencing and then withdrawing the arbitration to pursue a better forum constituted an abuse of process.

Consequently, the Applicant was ordered to pay the insurer's $2,000 assessment fee, and prohibited from commencing another arbitration for the same benefits until the fee is paid.

The appellant insurer appealed an arbitrator's decision finding it responsible for paying the insured's statutory accident benefits.

The appellant also sought to vary the order to introduce fresh evidence regarding a commercial use exclusion, arguing the insured was carrying a passenger for compensation at the time of the accident.

The Director's Delegate dismissed the appeal and the application for variation, finding that the appellant failed to exercise due diligence in obtaining the evidence for the initial hearing and that the arbitrator reasonably concluded the insured had elected to claim benefits from the appellant.

The insurer sought to enforce a previous arbitration decision ordering the applicant to repay weekly benefits and physiotherapy payments, but the exact amounts were not specified.

The hearing was reconvened to determine the amounts.

The applicant did not dispute the amounts but requested the hearing be reopened to order her family physician and the physiotherapy clinics to repay the amounts instead, alleging they were responsible for the misrepresentations.

The arbitrator dismissed the request, finding no statutory authority to vary the final decision or to make orders against non-parties, and declined to exercise discretion to reopen the hearing.

The appellant appealed an arbitrator's decision denying him weekly income benefits following a motor vehicle accident.

The appellant, who was self-represented on appeal, argued that he was denied a fair hearing because of inadequate interpretation services during the arbitration, particularly during his lawyer's closing submissions.

The Director's Delegate found that while there were minor interpretation issues, they did not affect the fairness of the hearing or result in an injustice.

The insurer's request for a special award on the basis that the appeal was frivolous or vexatious was denied, as the appellant's concerns were not groundless.

The appeal was dismissed and no expenses were awarded.

The applicant sought to withdraw her application for arbitration of statutory accident benefits in order to commence a civil proceeding.

The insurer consented to the withdrawal on the condition that the applicant pay the insurer's $2,000 assessment fee and be barred from reapplying for arbitration on the same issues.

The arbitrator granted the motion to withdraw, finding no abuse of process that would justify ordering the applicant to pay the assessment fee under section 282(11.2) of the Insurance Act.

The arbitrator declined to bar the applicant from reapplying, noting the insurer could renew its motion if she did so.

The respondent was seriously injured in a stock car racing accident at Mosport International Speedway.

He sought statutory accident benefits under his personal motor vehicle liability policy with the appellant insurer, arguing that the uninsured stock car was an "automobile" under the Insurance Act.

The arbitrator allowed the claim.

On appeal, the Director's Delegate rescinded the arbitrator's decision, holding that a custom-built stock car used exclusively for racing on a closed track is not an "automobile" for the purposes of the Statutory Accident Benefits Schedule.

The appeal was allowed and the claim for accident benefits was denied.

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

Allianz paid benefits but later disputed its obligation, arguing that General Accident was the priority insurer.

The insurers disputed whether Ontario Regulation 283/95, which mandates private arbitration for priority disputes, applied retroactively to this case.

The arbitrator held that the Regulation does not apply retroactively to disputes where the application for benefits was received before the Regulation came into force.

On the priority issue, the arbitrator found that the applicant's representative had made a valid election under section 268(5) of the Insurance Act to claim benefits from Allianz, and therefore Allianz was required to pay the benefits.

The appellant appealed an arbitrator's order allowing the respondent insurer to set off an award of arbitration expenses against an overpayment of statutory accident benefits owed by the appellant.

The appellant argued that the arbitrator lacked jurisdiction to order a set-off because it required the exercise of equitable jurisdiction.

The Director's Delegate dismissed the appeal, finding that the authority to order a set-off arises by necessary implication from the dispute resolution provisions of the Insurance Act, allowing the arbitrator to determine the ultimate balance to be paid between the parties.

The appellant appealed two arbitration decisions denying his claims for weekly benefits and supplementary medical and rehabilitation benefits following a motor vehicle accident.

The appellant argued that the arbitrator was biased, misapprehended the medical evidence, and improperly relied on surveillance evidence.

The Director's Delegate dismissed the appeals, finding no evidence of bias and concluding that the arbitrator's factual findings were supported by the evidence.

The arbitrator properly applied the 'essential tasks' test for weekly benefits and reasonably concluded that the appellant's requested psychological and computer training rehabilitation was not necessitated by the accident.

The appellant sought to appeal an arbitration order that dismissed his claim for statutory accident benefits after he failed to attend the arbitration hearing.

The notice of appeal was filed almost five months after the order, well beyond the 30-day limit.

The appellant requested an extension of time under section 283(3) of the Insurance Act, claiming he missed the hearing because he was misinformed about an adjournment and subsequently suffered a breakdown.

The Director's Delegate rejected the appellant's explanation as not credible and found no apparent grounds for granting relief on the merits of the claim.

The motion to extend the time was denied and the appeal was dismissed.

The appellant, a self-employed house painter, appealed an arbitration decision terminating his weekly income benefits and ordering repayment of interim benefits.

He sought to introduce a new medical report on appeal to address the arbitrator's concerns about his chronic pain syndrome diagnosis.

The Director's Delegate refused to admit the new evidence, finding it would not have affected the result.

The Delegate upheld the arbitrator's conclusion that the appellant was substantially able to perform the essential tasks of his occupation, noting that job flexibility is an appropriate consideration for self-employed individuals.

The Delegate also affirmed the arbitrator's reliance on the mediator's report over the appellant's testimony regarding an alleged agreement to pay benefits during rehabilitation.

The appeal was dismissed, but the appellant was awarded his reasonable appeal expenses due to the merit of the issues raised.

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

He sought a declaration at arbitration regarding his entitlement to payment for expenses incurred by his rehabilitation case manager for communicating with his solicitors, despite all accounts having been paid in full by the insurer.

The insurer objected on the basis that there was no substantive dispute.

The arbitrator dismissed the application, finding that an arbitrator has no jurisdiction under the Insurance Act to make pronouncements or issue guidelines in the absence of a specific dispute over entitlement or quantum of benefits.

The applicant was injured in a motor vehicle accident and received statutory accident benefits before signing a full and final release in exchange for a lump sum settlement.

He later sought further benefits, arguing the settlement should be set aside due to misrepresentation, unconscionability, and undue influence.

The arbitrator held that while arbitrators can determine if a settlement agreement exists as a defence to a claim for benefits, they lack the equitable jurisdiction to set aside an otherwise valid agreement.

The applicant is precluded from proceeding with the arbitration until a court of competent jurisdiction sets aside the settlement agreement.