Statutory Accident Benefits Schedule matters (SABS) - OFSCDRS

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

The insurer denied benefits and raised the preliminary issue of wilful misrepresentation.

The applicant objected to the late service of the insurer's expert reports and argued the insurer failed to provide proper notice of the reasons for denying benefits.

The arbitrator allowed the late expert reports, finding no procedural unfairness or prejudice to the applicant.

The arbitrator also held that the insurer provided sufficient notice of its wilful misrepresentation defence in its Response to the Application for Arbitration, allowing the preliminary issue hearing to proceed.

The applicant was injured while attempting to avoid a collision as a pedestrian and applied for statutory accident benefits from the insurer.

The parties proceeded to arbitration on three preliminary issues.

After hearing evidence on the first preliminary issue, the arbitrator declined to issue a decision immediately, finding it necessary in the interests of fairness and efficiency to reserve the decision until the hearing concluded with respect to all three preliminary issues.

The insurer brought a motion to exclude the evidence and report of the applicant's treating physiatrist, arguing he was no longer a qualified practitioner under the Evidence Act due to the revocation of his medical license for professional misconduct.

The arbitrator dismissed the motion, holding that the Statutory Powers Procedure Act permits the admission of relevant evidence and that the prejudice to the applicant in excluding his long-term treating physician outweighed the insurer's concerns of impropriety.

The arbitrator also admitted transcripts of several witnesses from a previous arbitration hearing on consent.

The applicant was injured in a motor vehicle accident and applied for a caregiver benefit under section 13 of the Statutory Accident Benefits Schedule, claiming she was the primary caregiver for her adult brother who suffers from schizophrenia and resides in a mental health facility.

The arbitrator found that the applicant did not qualify for the benefit because she did not reside with her brother, as required by the Schedule, and because the facility staff, rather than the applicant, provided the primary caregiving services.

The preliminary issue was resolved in favour of the insurer.

The applicant sought statutory accident benefits for housekeeping and home maintenance expenses following a motor vehicle accident.

The applicant failed to attend the arbitration hearing.

The arbitrator proceeded in his absence and dismissed the claim, finding insufficient evidence to establish a substantial inability to perform pre-accident housekeeping duties.

The insurer's request to add claims for its expenses and for a frivolous proceeding was denied due to lack of notice to the applicant.

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

Following an initial arbitration and subsequent appeal that remitted the matter for a new hearing, the insurer sought production of independent medical examinations (IEs) obtained in the applicant's related tort action.

The arbitrator considered the recent Court of Appeal decision in Tanner and the tribunal's approach to importing documents from civil actions.

Finding that the insurer had a compelling reason for not obtaining its own updated medical assessments due to the intervening appeal, the arbitrator ordered the applicant to produce the tort IEs in her possession for the period between the first hearing and the appeal decision.

The applicant sought statutory accident benefits after a tenant mistakenly drove her vehicle into the side of his house.

The impact caused a loud noise and shaking, prompting the applicant to panic and run to check on his children.

While running down the stairs, he tripped and fell, sustaining injuries.

The insurer denied benefits, arguing the injuries were not caused by an 'accident' as defined in the Schedule.

The arbitrator found that the car hitting the house directly caused the applicant's injuries, as the sequence of events was one continuous incident without an intervening act.

The arbitrator concluded the applicant was involved in an accident within the meaning of the Schedule.

The insurer brought a motion for the production of medical and employment records from several non-parties.

The applicant did not object to the production and had previously attempted to obtain the records.

The arbitrator ordered the non-party doctors to produce their complete charts, finding that reasonable efforts had been made and the doctors had a reasonable opportunity to respond.

However, the arbitrator declined to order the non-party employer to produce employment records, as there was insufficient evidence that the employer had been properly served with the motion record and given an opportunity to respond.

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

The insurer terminated these benefits based on a Disability Designated Assessment Centre (DAC) report.

The applicant argued the DAC assessment was flawed and did not comply with the guidelines, seeking reinstatement of benefits.

The arbitrator found that the DAC assessment substantially complied with the guidelines and that the termination was valid under section 37 of the Schedule.

The arbitrator also held that the insurer was entitled to conduct further reasonably necessary medical examinations under section 42 to determine entitlement to post-104 week benefits.

The applicant, who suffered from secondary progressive multiple sclerosis, was injured in a motor vehicle accident when she was knocked to the ground by a reversing truck.

She applied for statutory accident benefits, claiming the accident accelerated her deterioration and caused a complete inability to carry on a normal life.

The arbitrator found that while the accident caused a short-term exacerbation of her symptoms, it did not materially contribute to her long-term impairments or continuously prevent her from engaging in substantially all of her pre-accident activities.

Claims for non-earner benefits and assistive devices were dismissed, but the cost of two assessments was awarded as they were reasonably incurred.

The applicant was injured in a 1996 motor vehicle accident and sought various statutory accident benefits, including supplementary medical benefits for an adjustable bed and physiotherapy, rehabilitation benefits for moving expenses and taxi fares, and housekeeping and home maintenance expenses.

The arbitrator found that the applicant had a significant pre-existing medical and psychological history.

The claims for the bed, physiotherapy, moving expenses, and housekeeping were dismissed, as the arbitrator concluded they were either not reasonably necessary or not causally related to the 1996 accident.

However, the claim for taxi expenses to attend occasional social activities was allowed as a reasonable rehabilitation measure to facilitate social reintegration.

Claims for a special award and arbitration assessment fees were dismissed.

The insurer brought a motion to dismiss the applicant's arbitration for statutory accident benefits due to the applicant's repeated failure to comply with production and cost orders.

The arbitrator declined to dismiss the arbitration, finding that the specific notice prerequisites for dismissal without a hearing under Rule 68 of the Dispute Resolution Practice Code had not been met.

However, to prevent an abuse of process under Rule 65.7, the arbitrator stayed the arbitration pending the applicant's compliance with all previous orders and payment of $500 in costs for the motion.

The applicant claimed statutory accident benefits following an alleged motor vehicle accident.

The insurer denied the claim, alleging the accident was staged and the damage was caused by a blunt object.

The arbitrator found that while an incident involving the two vehicles did occur, the applicant failed to prove he suffered a compensable impairment arising from the accident.

Furthermore, the arbitrator found that the applicant made wilful false statements regarding his medical history and prior accidents, thereby forfeiting his right to recover indemnity under section 233(1)(c) of the Insurance Act.

The application for benefits was dismissed.

The insurer appealed an arbitration decision ordering it to pay income replacement benefits beyond the 104-week mark, a maximum special award, and arbitration expenses.

The Director of Arbitrations upheld the ongoing entitlement to income replacement benefits, finding that the evidence supported the conclusion that the insured suffered a complete inability to engage in suitable employment.

However, the special award was reduced to $5,000 because the insurer's initial reliance on its experts was not unreasonable, and the arbitration expenses were slightly reduced to exclude pre-mediation legal work.

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

When the matter proceeded to an arbitration hearing, the Applicant failed to attend.

The Arbitrator dismissed the application for arbitration due to the Applicant's failure to lead evidence.

The Insurer sought its expenses and a special award for a frivolous or vexatious proceeding.

The Arbitrator ordered the Applicant to pay the Insurer's reasonable expenses of $2,554.89 but declined to order a penalty for a frivolous proceeding because the relevant statutory provision had been repealed and the Insurer failed to provide advance notice of the claim.

The applicant was injured in a motor vehicle accident and applied for enhanced statutory accident benefits, claiming a catastrophic impairment based on a brain impairment resulting in a Glasgow Coma Scale (GCS) score of 9 or less.

The insurer denied the claim, arguing the GCS scores were confounded by medical interventions and seizures, and that the applicant did not maintain the score for a reasonable time.

The arbitrator found that the applicant maintained a GCS score of 9 or less for about one hour after the accident, which was a reasonable time given the circumstances, and that the scores were not confounded by intubation during that period.

The applicant was designated as catastrophically impaired.

The Applicant was injured in a motor vehicle accident while receiving WSIB benefits for a prior workplace injury.

She applied for income replacement benefits (IRBs) from her auto insurer, claiming she had a prospective contract of employment to return to her pre-injury job once physically fit.

The Arbitrator found that her return to work was entirely contingent on her being physically capable of performing her pre-injury duties, which constituted a true condition precedent that was not satisfied at the time of the accident.

The Arbitrator concluded there was no reasonable prospect she would have returned to her prior employment within one year of the accident.

The claim for IRBs was dismissed.

The insurer brought a motion to stay the arbitration proceedings and prohibit the insured from receiving income replacement benefits until he attended independent medical examinations (neurology, physiatry, and psychology).

The arbitrator dismissed the motion, finding that the requested examinations were not reasonably necessary at this stage to adjust the claim, but rather appeared to be sought for the tactical purpose of marshalling evidence for the upcoming arbitration.

The insurer had prior notice of the insured's neurological concerns but failed to follow up in a timely manner.

The insurer brought a motion to compel the insured to attend an independent medical examination by a psychiatrist under section 42 of the Statutory Accident Benefits Schedule.

The insured refused to attend, arguing the examination was for medical-legal purposes rather than determining entitlement to a benefit.

The arbitrator dismissed the motion, finding that arbitrators at the Financial Services Commission of Ontario lack jurisdiction to order an insured to attend a medical examination.

The arbitrator also noted that the insurer's delay in requesting the examination until the eve of the hearing would cause significant prejudice to the insured.

The applicant, who suffered a catastrophic brain injury when struck by a car as a pedestrian, applied for ongoing income replacement benefits beyond the 104-week mark.

The insurer terminated benefits based on a DAC assessment concluding the applicant could work.

The arbitrator found the DAC assessment inherently flawed and preferred the evidence of the applicant's treating practitioners, which demonstrated that despite numerous attempts to work, the applicant's cognitive, behavioural, and physical deficits rendered him completely unable to engage in suitable employment.

The arbitrator ordered the insurer to pay ongoing income replacement benefits with interest, declined to reopen the hearing for new evidence, and gave notice that a special award for unreasonably withholding benefits was being considered.