Statutory Accident Benefits Schedule matters (SABS) - OFSCDRS

The insurer appealed an arbitrator's order requiring it to pay the insured $600 per week in statutory accident benefits and sought a stay of the order pending the appeal under section 283(6) of the Insurance Act.

The Director's Delegate determined that the insurer bore the onus of establishing why a stay should be granted, based on factors including the bona fides of the appeal, the substance of the grounds, and hardship to the parties.

Balancing the insured's financial hardship against the insurer's risk of non-recovery, the Delegate granted a partial stay for arrears prior to February 4, 1992, but ordered the insurer to pay the ongoing $600 weekly benefits pending the appeal's disposition.

The insurer appealed an arbitrator's order requiring it to provide the catastrophically injured insured with a suitably modified mini-van under section 6(1)(f) of the No-Fault Benefits Schedule.

The insurer argued that transportation expenses were exhaustively covered by section 6(1)(d) and that a van was not 'necessary' for rehabilitation.

The insured cross-appealed, seeking a full-size custom van and a special award.

The Director's Delegate dismissed the insurer's appeal, finding that section 6(1)(f) authorized the provision of a motor vehicle and that a broad definition of rehabilitation included psychological adjustment and independence.

The cross-appeal for a full-size van was also dismissed, as the mini-van was deemed a reasonable expense.

The Director's Delegate refused to admit fresh evidence on the special award issue, finding it could have been adduced at the original hearing.

The applicant was injured in a motor vehicle accident and received weekly income benefits until the insurer terminated them, arguing she was no longer disabled.

The applicant, a real estate agent, claimed she could not work the long and unpredictable hours required by her occupation due to ongoing neck and back pain.

The arbitrator preferred the medical evidence of the applicant's treating specialist over the insurer's expert, finding that the ability to perform essential tasks must incorporate the ability to perform them in a manner that renders the work remunerative.

The arbitrator concluded the applicant suffered a substantial inability to perform the essential tasks of her occupation and ordered the reinstatement of weekly income benefits.

The applicant was injured in a motor vehicle accident and claimed no-fault weekly benefits.

The insurer deducted the applicant's pre-existing workers' compensation pension and a private disability insurance benefit from the weekly benefit amount.

The arbitrator held that the workers' compensation pension for a permanent disability was not a payment for loss of income and therefore not deductible.

However, the private disability insurance benefit was found to be a payment for loss of income received under an income continuation benefit plan, and was therefore deductible from the no-fault weekly benefit.

The applicant was injured in a motor vehicle accident and received weekly income benefits until the insurer terminated them.

The applicant sought reinstatement of the benefits and compensation for his family's suffering due to the dispute.

The arbitrator found that surveillance evidence showed the applicant performing activities such as re-shingling a roof, contradicting his claim of substantial inability to perform essential tasks.

The application for weekly income benefits was dismissed, and the claims for family compensation were also denied as they did not fall within the statutory definitions.

The Applicant, a self-employed taxicab driver, was injured in a motor vehicle accident and applied for weekly income benefits.

The Insurer initially paid benefits based on the Applicant's verbal declaration but later reduced payments to the minimum statutory amount when the Applicant failed to provide satisfactory documentary proof of his gross weekly income.

The arbitrator found that the Applicant failed to establish a gross weekly income exceeding the statutory minimum of $232.00 per week.

The Applicant was awarded the minimum benefit of $185.60 per week, and the Insurer was ordered to be repaid $1,695.60 for the initial overpayment.

The Applicants were injured in a motor vehicle accident and applied for no-fault weekly income benefits.

They argued that the value of their unpaid services in renovating a cottage for their business should be included in calculating their pre-accident gross weekly income, and alternatively, that their partnership agreement constituted an offer of employment.

The arbitrator held that the statutory definition of income does not include the imputed value of unpaid services.

The arbitrator further held that the partnership agreement did not constitute a legitimate offer of employment under the No-Fault Benefits Schedule.

The Applicants were entitled only to the minimum statutory benefit.

The applicant was injured in a motor vehicle accident two days after starting a new job.

The insurer calculated his weekly income benefits by averaging his income over the full 52 weeks prior to the accident, resulting in a benefit of $304.53 per week.

The applicant argued his benefits should be based on his regular weekly rate at the time of the accident.

The arbitrator held that under Section 12(7) of the No-Fault Benefits Schedule, the applicant's gross weekly income should be calculated by averaging his income over the weeks he was actually employed in the 52 weeks before the accident, disregarding periods of unemployment.

This resulted in the applicant being entitled to the maximum weekly benefit of $600.00.

The applicant, a construction contractor, was injured in a rear-end motor vehicle accident and claimed weekly income benefits.

The insurer terminated benefits, arguing the applicant was no longer substantially unable to perform the essential tasks of his occupation, relying in part on surveillance evidence.

Following an arbitration hearing, the arbitrator found that the applicant was substantially unable to perform his essential tasks during the disputed period.

The arbitrator relied on the applicant's testimony, corroborating evidence from tradesmen, and medical reports, noting that the applicant's brief visits to a job site did not demonstrate an ability to work.

The applicant was awarded entitlement to benefits and arbitration expenses.

The applicant was injured when her car door fell off its hinges.

She received weekly income benefits until the insurer terminated them based on medical reports indicating she could return to work.

The applicant sought arbitration, claiming ongoing chronic pain prevented her from performing her job as an accounts receivable clerk.

The arbitrator dismissed the claim, finding the medical evidence did not support a causal link between the minor trauma and her ongoing complaints.

Furthermore, video surveillance evidence contradicted her claims of physical limitation, leading the arbitrator to conclude she had not established a substantial inability to perform the essential tasks of her employment.

The insurer appealed an interim order of an arbitrator that limited the scope of the arbitration to the specific issues raised by the insured person.

The insurer argued that once an insured person refers a matter to arbitration, the arbitrator has jurisdiction to hear all disputes between the parties, including the insurer's claims for overpayment or other benefits.

The Director of Arbitrations dismissed the appeal, holding that the Insurance Act restricts the arbitrator's jurisdiction to the specific matter referred by the insured person and any issues that naturally or consequentially flow from it, unless the parties agree otherwise.

The applicant was injured in a motor vehicle accident and applied for arbitration regarding her continuing entitlement to weekly income and care benefits after they were terminated.

The insurer sought to raise additional issues, including repayment of care benefits already paid, repayment of transportation expenses, and a ruling that it was not required to pay rehabilitation expenses.

The arbitrator held that she had jurisdiction to determine issues related to the specific benefits raised by the applicant, including the insurer's claim for repayment of those benefits.

However, the arbitrator lacked jurisdiction to determine disputes over entirely different benefits (transportation and rehabilitation expenses) that the applicant had not referred to arbitration.

The applicant, a self-employed vendor of cosmetic products, was injured in a motor vehicle accident and claimed weekly income benefits at the maximum rate of $600.00 per week.

The insurer disputed the applicant's documentation of his earnings and paid $252.00 per week.

At arbitration, the arbitrator found the applicant's evidence regarding his sales and profits to be contradictory, unreliable, and largely unsubstantiated.

Relying only on objectively verifiable documentation, the arbitrator calculated the applicant's gross weekly income to be $232.00, entitling him to the statutory minimum benefit of $185.00 per week.

The applicant was ordered to repay the insurer the $67.00 weekly overpayment.

The applicant was injured in a motor vehicle accident shortly after being terminated from his employment.

He received a severance package, including a $22,700 lump sum transferred to an RRSP.

The insurer deducted this amount from his no-fault weekly income benefits, arguing it was a payment for loss of income.

The arbitrator held that the severance payment was not a payment for loss of income under s. 12(4)(b) of the No-Fault Benefits Schedule because it was payable regardless of whether the applicant obtained re-employment.

The arbitrator also dismissed the insurer's preliminary motion for disqualification based on apprehension of bias, and denied the applicant's request for a special award, finding the insurer's position was based on a legitimate legal dispute.

The applicant was injured in a motor vehicle accident and received weekly income benefits until the insurer terminated them based on an orthopaedic surgeon's report.

The applicant sought arbitration for benefits from January to March 1991.

The arbitrator preferred the evidence of the applicant's family physician, who examined him on an ongoing basis, over the insurer's specialist who saw him only once.

The arbitrator found the applicant suffered a substantial inability to perform the essential tasks of his employment and awarded weekly income benefits until March 17, 1991, with interest.

The applicant, a self-employed taxi driver, was injured in a motor vehicle accident and claimed weekly income benefits at the maximum rate of $600 per week.

The insurer disputed the calculation of his income, preferring to rely on his 1990 tax return rather than his daily run sheets.

The arbitrator accepted the run sheets as prima facie evidence of earnings but adjusted the expenses based on the 1990 tax return, concluding the applicant was entitled to a weekly benefit of $252.10.

The applicant was injured in a motor vehicle accident and could no longer lift her handicapped child into her vehicle.

She traded in her van for a comparable vehicle that could accommodate a wheelchair lift.

The insurer disputed the trade-in value she received and the total replacement cost.

The arbitrator found that the applicant acted reasonably by shopping at three dealerships and accepting the best trade-in offer, and ordered the insurer to pay the full difference in cost between the trade-in and the replacement vehicle.

The Applicant sought weekly income benefits following a motor vehicle accident while driving an uninsured vehicle.

The arbitrator determined that the Toronto Transit Commission, as the owner of the other vehicle involved, was the proper insurer.

However, the arbitrator dismissed the claim for benefits, finding that the Applicant had never been employed as claimed and that the claim was entirely fraudulent.

The arbitrator noted the inability to award costs against a fraudulent applicant under the existing legislation.

The applicant, a pedestrian whose foot was run over by a car, sought weekly no-fault benefits after the insurer terminated them.

During the arbitration, the insurer attempted to introduce undisclosed surveillance video to impeach the applicant's credibility.

The arbitrator excluded the video, applying the rule in Browne v. Dunn, because the insurer failed to put the evidence to the applicant during cross-examination, which would cause undue prejudice and delay in an arbitration context.

On the merits, the arbitrator found that while the applicant suffered discomfort from his injuries, he failed to establish a substantial inability to perform his essential tasks.

The application for weekly benefits and interest was dismissed.

The self-employed applicant was injured in a motor vehicle accident and claimed maximum weekly income benefits of $1050 under the No-Fault Benefits Schedule.

The insurer paid $755.23 based on incomplete financial records and later sought to reduce the amount to $523 based on a forensic accounting report.

The arbitrator accepted the insurer's accounting evidence, finding the applicant failed to produce adequate records and deliberately delayed the hearing.

The arbitrator set the weekly benefit at $523, ordered the applicant to repay the overpayment, and denied the applicant's claims for interest, a special award, and costs.