Other Tribunals - OFSCDRS

The appellant insurer appealed an arbitration decision finding it responsible for paying accident benefits to the injured respondent.

The injured respondent was a passenger in a vehicle insured by the respondent insurer, but was the spouse of a named insured under the appellant's policy.

The Director's Delegate held that the injured respondent qualified as an 'insured person' under the appellant's policy because she was an occupant of 'any other automobile'.

Under the priority rules, she was required to claim benefits from her spouse's insurer.

The appeal was dismissed.

The Director's Delegate also held there was no jurisdiction to award appeal expenses between insurers.

In a supplementary decision, the insurer requested to setoff an overpayment of benefits against the insured's arbitration expenses previously ordered by another arbitrator.

The arbitrator denied the request, finding that the previous arbitrator specifically awarded partial expenses to the insured because the insurer had called unnecessary witnesses and prolonged the proceedings.

Allowing a setoff would undermine the intention that the insured not bear the costs of the insurer's inefficient conduct.

The applicant was injured in a motor vehicle accident and received weekly income benefits for 156 weeks.

The insurer terminated benefits, arguing the applicant did not meet the stricter disability test under section 12(5)(b) of the Statutory Accident Benefits Schedule.

The arbitrator determined that the 156-week period refers to 156 weeks of disability, not 156 weeks from the accident date.

On the merits, the arbitrator found that while the applicant could not return to his heavy pre-accident work as a millwright, he had transferrable skills and was capable of engaging in suitable light-duty employment.

The claim for ongoing weekly income benefits was dismissed.

The arbitrator also denied the applicant's claim for a special award, finding the insurer did not unreasonably withhold payments, but awarded the applicant his arbitration expenses.

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

The insurer denied benefits based on collateral deductions.

The applicant applied for arbitration solely on the issue of collateral benefits deduction.

The insurer sought to add the issue of entitlement to the arbitration.

The arbitrator held that under the amended section 282(3) of the Insurance Act, the arbitrator shall determine all issues in dispute, whether raised by the insured or the insurer.

The insurer was permitted to raise the issue of entitlement at the hearing.

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

The insurer alleged the claim was fraudulent.

At the commencement of the arbitration hearing, the self-represented applicant sought to withdraw her dispute.

The arbitrator permitted the withdrawal but found the applicant's failure to provide advance notice of her intention to withdraw constituted an abuse of process.

The applicant was ordered to pay the insurer $2,000 for the assessment fee.

The insurer's claim for arbitration expenses was denied as the relevant statutory amendments did not apply retroactively.

The applicant applied for statutory accident benefits after a motor vehicle accident in his employer's parking lot.

The insurer denied the claim, arguing the applicant was entitled to workers' compensation benefits.

At mediation, the parties reached a tentative agreement, but the insurer later refused to pay upon learning the Workers' Compensation Board had allowed the applicant's claim for health care benefits while denying lost time benefits.

The Arbitrator held that the mediation agreement was based on a misunderstanding and was not binding.

Furthermore, because the applicant was entitled to receive some workers' compensation benefits, section 20 of the Statutory Accident Benefits Schedule precluded him from receiving accident benefits.

He was also not entitled to interim benefits under section 21 because he had elected to receive workers' compensation benefits and the WCB had already determined his entitlement.

The applicant was injured in a motor vehicle accident and received statutory accident benefits from the insurer until they were terminated.

She applied for arbitration claiming ongoing weekly income benefits, medical expenses, and a special award.

The arbitrator found that the applicant suffered a substantial inability to perform the essential tasks of her employment as a dispatcher/cashier due to ongoing physical and psychological injuries, including right arm weakness, anxiety, and depression caused by the accident.

The arbitrator awarded weekly income benefits for the disputed two-year period.

Claims for nutritional counselling, meal replacements, and a special award were dismissed due to insufficient evidence.

The arbitrator also ruled that the new expense provisions under the Automobile Insurance Rate Stability Act did not apply retroactively, denying the insurer's claim for expenses and awarding the applicant her expenses of the proceeding.

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

The Insurer refused to pay income replacement benefits, alleging the Applicant failed to disclose that her 21-year-old son was a licensed driver living in the household, which would have resulted in a substantially higher premium.

The Arbitrator found that the Applicant knowingly and intentionally failed to disclose material facts to avoid a higher premium.

Consequently, the Applicant was excluded from receiving income replacement benefits under section 58(3)(a) of the Schedule, and her application for arbitration was dismissed.

The Applicant claimed statutory accident benefits following two alleged motor vehicle accidents.

In a previous decision, the arbitrator found the Applicant was not involved in the second accident and had made a serious misrepresentation to the Insurer.

The Insurer sought repayment of benefits paid after the second accident and a further assessment for the first accident claim.

The arbitrator dismissed the request for a further assessment, finding the first accident claim was not frivolous or vexatious simply because it was dismissed for failure to pay an initial assessment.

However, the arbitrator ordered the Applicant to repay $122,151.21 in benefits relating to the second accident, finding she materially contributed to the overpayment through her misrepresentation.

The applicant, a taxi driver, was stabbed by a passenger while waiting to be paid his fare.

He applied for statutory accident benefits, but the insurer denied the claim on the basis that the injuries were not caused by an 'accident' as defined in the Schedule.

The arbitrator applied the two-part test from Amos and found that the applicant was engaged in the ordinary use and operation of a motor vehicle at the time of the assault, and that there was a direct causal link between the use and operation of the taxi cab and the injuries.

The arbitrator concluded that the applicant was injured as a result of an accident and is entitled to proceed to arbitration.

The applicant was injured in a motor vehicle accident and received statutory accident benefits as well as CPP disability benefits.

The insurer argued that the parties had previously reached a binding settlement that CPP benefits were deductible, and alternatively, that CPP benefits are payments for loss of income and thus deductible under the Schedule.

The arbitrator found that no binding settlement was reached as there was no consideration given for the applicant's prior acknowledgement of the state of the law.

Furthermore, following appellate authority, the arbitrator held that CPP disability benefits are non-indemnity payments triggered by disability, not payments for loss of income, and therefore are not deductible from the applicant's gross weekly income.

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

In a prior preliminary decision, the arbitrator found the applicant misrepresented her involvement in a second accident and ordered her to pay a $1,000 assessment before the hearing could proceed.

The applicant failed to pay the assessment and did not appear at the scheduled hearing.

Consequently, the arbitrator dismissed her application for arbitration.

The insurer's claim for repayment of benefits was adjourned to a later date to ensure fairness, as the applicant may have mistakenly believed no hearing would proceed until the assessment was paid.

The arbitrator also confirmed jurisdiction to hear the insurer's repayment claim under the amended section 282(3) of the Insurance Act.

The applicant sought an assessment of legal expenses incurred during an arbitration and the subsequent assessment hearing.

The insurer argued the legal bill exceeded the maximum hours allowable under the Legal Aid Act.

The arbitrator allowed the legal expenses for the arbitration period, finding them reasonable given the complexity and duration of the hearing.

However, the arbitrator denied the expenses for the assessment hearing itself, ruling that it is a separate proceeding not covered by the Expenses Schedule.

The applicant sought to withdraw his application for arbitration regarding statutory accident benefits one month before the scheduled hearing, intending to proceed in court instead.

The insurer objected, arguing the withdrawal was an abuse of process and seeking costs under the Insurance Act and Practice Code.

The arbitrator found the applicant had not acted for an improper purpose or to harass the insurer, and therefore the withdrawal was not an abuse of process.

The withdrawal was permitted on the condition that the applicant could not re-apply for arbitration on the same issues.

The applicant's request for expenses of the withdrawal hearing was denied.

The appellant appealed an arbitration decision that denied him additional weekly income benefits following multiple motor vehicle accidents.

The appellant, representing himself on appeal, argued that the arbitration hearing should not have taken place because the issues were decided in a previous arbitration and he did not receive proper notice or full disclosure.

The Director's Delegate found no error in the arbitration process, noting that the previous arbitration only determined which issues could proceed and that the appellant's counsel at the hearing did not object to the proceedings or the admission of expert evidence.

The appeal was dismissed and the arbitration order was confirmed.

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

Both Kingsway General and Lloyd's denied the claim, each arguing the other was responsible.

The preliminary issue was whether Kingsway General's policy was validly cancelled prior to the accident due to a missed premium financing payment to its related company, Kingsway Financial.

The arbitrator found that the premium financing arrangement was an attempt to circumvent the statutory notice requirements for cancellation under the Statutory Conditions.

The corporate veil was pierced, and the cancellation was deemed invalid for failing to provide statutory notice.

Kingsway General was held responsible for paying the benefits.

The applicants were injured in a motor vehicle accident and claimed statutory accident benefits from the insurer, including income replacement benefits, caregiver benefits, and taxi expenses.

The arbitrator found that the insurer was liable to pay benefits as there was no other available insurance.

However, the arbitrator dismissed the claims for income replacement benefits, finding that neither applicant had a legitimate contract of employment evidenced in writing at the time of the accident, and the female applicant did not suffer a substantial inability to perform the essential tasks of her pre-accident self-employment.

The claims for caregiver benefits and taxi expenses were also dismissed due to a lack of objective medical evidence and failure to prove the expenses were reasonably incurred.

The applicants were awarded one-third of their arbitration expenses.

The appellants appealed an arbitration decision that denied their claims for additional accident benefits, ordered them to repay specified amounts to the insurer, and denied their arbitration expenses.

The arbitrator had found the appellants to be unreliable witnesses and concluded they failed to establish their entitlement to benefits.

On appeal, the Director's Delegate dismissed the appeal, finding ample evidence to support the arbitrator's findings and noting that the appeal improperly sought to second-guess the arbitrator's assessment of the evidence.

Requests for appeal expenses and the insurer's assessment fee were also denied.

The applicant claimed statutory accident benefits following a motor vehicle accident but failed to take any steps to advance the arbitration after a preliminary issue was decided in December 1995.

The insurer brought a motion to dismiss the arbitration.

The applicant did not attend the hearing despite receiving proper notice.

The arbitrator proceeded in the applicant's absence under the Statutory Powers Procedure Act and dismissed the claims on the merits, finding the applicant had abandoned the arbitration and failed to satisfy his burden of proof.

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

The insurer denied coverage, claiming the applicant had requested to delete all road coverages the day before the accident.

The applicant argued the broker made an error regarding the effective date of the coverage change.

The arbitrator found that the applicant was an insured person at the time of the accident because the broker's error could not unilaterally alter the contract.

However, the arbitrator also held that the applicant was barred from proceeding with his claim because he failed to submit a completed application for statutory accident benefits within the required time limits under section 22(1)(b) of the Statutory Accident Benefits Schedule, and the insurer's denial of coverage did not estop them from relying on this requirement.