Statutory Accident Benefits Schedule matters (SABS) - OFSCDRS

York Fire applied to revoke a previous arbitration order which found that Dorna Osbourne was the spouse of its insured, Winston Smart, making York Fire responsible for the applicant's statutory accident benefits.

York Fire introduced new evidence demonstrating that both Osbourne and Smart had lied under oath during the initial hearing about their marital histories and continuous cohabitation.

The arbitrator admitted the new evidence, found the witnesses' credibility severely undermined, and revoked the previous order.

The arbitrator concluded that Osbourne and Smart were not spouses at the time of the accident, and ordered Allstate to respond to the applicant's claims.

The Applicant was injured in a motor vehicle accident and received weekly income benefits until they were terminated by the Insurer.

The Insurer raised a preliminary issue that the Applicant was no longer eligible for benefits under section 16(2) of the Schedule because she had returned to work for an aggregate of more than 90 days after the second anniversary of the accident.

The Arbitrator held that the phrase 'for periods of up to ninety days' in section 16(2) means one or more continuous periods of up to 90 days each, not an aggregate of shorter periods.

Since the Applicant had not worked for a continuous period of 90 days, she remained eligible for benefits.

The applicant, a pedestrian, was struck by a motor vehicle insured by Economical.

She applied for statutory accident benefits from Wellington under a policy issued to her future husband, claiming she was his spouse at the time of the accident.

The arbitrator found that although the applicant and the named insured had previously cohabited and had children together, they had ceased cohabiting for over a year prior to the accident.

Consequently, the applicant did not meet the definition of 'spouse' under section 224(1) of the Insurance Act at the time of the accident and was not an 'insured person' under the Wellington policy.

Economical was held liable to pay the statutory accident benefits.

The applicant applied for arbitration after the insurer stopped paying weekly statutory accident benefits.

Following the application, the applicant was convicted of operating the motor vehicle involved in the accident without liability insurance.

The applicant did not appear at the telephone hearing.

The arbitrator found that under section 17(1)(c) of the Statutory Accident Benefits Schedule, the insurer is not required to pay weekly benefits to a driver convicted of operating an uninsured automobile.

The applicant's claim for weekly benefits was dismissed.

The Applicant was injured in a motor vehicle accident and received statutory accident benefits, as well as private disability insurance benefits.

The Insurer terminated her weekly income benefits 156 weeks after the accident, arguing that the 156-week period under section 12(5) of the Statutory Accident Benefits Schedule ran continuously from the date of the accident.

The arbitrator held that the 156-week period refers to 156 weeks of payments made by the Insurer, not 156 weeks from the accident or 156 weeks of disability.

Because the Insurer had not yet paid 156 weeks of benefits (due to the private insurance payments), the Applicant was entitled to further weekly income benefits.

The claim for a special award was dismissed, as the Insurer's interpretation was not unreasonable in this case of first impression.

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

After mediation failed, she applied for arbitration regarding weekly income benefits and other expenses.

The Insurer raised a preliminary issue, arguing the Applicant was precluded from proceeding to arbitration because she had commenced a separate court action against the Insurer for different medical expenses arising from the same accident.

The arbitrator dismissed the preliminary objection, finding that the Insurance Act does not compel an insured to refer all disputes to a single forum, provided the specific matters referred to arbitration are distinct from those in the court action.

The applicant sought assessment of expenses related to the expert testimony of his family doctor at an arbitration hearing.

The doctor billed for preparation, travel, and attendance time.

The arbitrator held that under section 5(1)2 of Ontario Regulation 664, expert witness expenses are limited to the reasonable time the expert is in attendance at the hearing site, and do not include pre-arbitration preparation or travel time.

The insurer was ordered to pay $112.50 for the 45 minutes the doctor spent at the hearing.

The applicant was injured in a motor vehicle accident and sought reinstatement of weekly income benefits, arguing she was on a 'temporary lay-off' from her work as a real estate salesperson and thus entitled to benefits under section 12 of the Statutory Accident Benefits Schedule.

The arbitrator found that the applicant had resigned from her position 15 months prior to the accident, actively sought other employment, and was therefore unemployed rather than on a temporary lay-off.

The claim for interim benefits was also denied due to a lack of medical evidence.

The applicant's entitlement to benefits will be considered under section 13 of the Schedule at a continuation of the hearing.

The insurer moved for an order compelling the insured to attend a psychological examination pursuant to subsection 23(2) of the Statutory Accident Benefits Schedule.

The insured argued the insurer's right to require an examination expired after mediation.

The arbitrator held that the insurer was entitled to require the examination to assess the ongoing claim for weekly benefits.

However, the arbitrator concluded that she lacked the express or implied statutory authority under the Insurance Act or the Schedule to compel the insured to attend the examination.

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

The parties disputed entitlement to weekly income benefits for a four-week period, supplementary medical and rehabilitation expenses, and a special award.

The arbitrator found the Applicant was entitled to the weekly income benefits, which the Insurer conceded partway through the hearing.

The arbitrator also awarded partial housekeeping, babysitting, and dental expenses, but denied transportation and optical expenses.

A special award was granted under section 282(10) of the Insurance Act due to the Insurer's unreasonable delay in paying the weekly income benefits and certain housekeeping expenses.

The applicant, a real estate agent, was injured in a motor vehicle accident and applied for statutory accident benefits.

The insurer disputed the calculation of her pre-accident income, arguing that commissions received after the accident for sales negotiated before the accident should not be included in her pre-accident income.

The arbitrator held that the commissions were earned prior to the accident when the work was performed, and should be included in the calculation of her pre-accident income.

The applicant was awarded weekly income benefits of $600.00, and the insurer's claim for repayment was dismissed.

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

The insurer terminated benefits, arguing the applicant did not meet the stricter post-156 week test of being continuously prevented from engaging in any occupation for which he is reasonably suited by education, training, or experience.

The arbitrator found that while the applicant had chronic injuries preventing heavy physical work, he was capable of performing lighter or sedentary work consistent with his education and experience.

The arbitrator concluded the applicant's failure to pursue such work was due to a lifestyle choice rather than physical restrictions.

The application for ongoing benefits was dismissed, but the applicant was awarded expenses.

The applicant's son was fatally injured in a motor vehicle accident.

The applicant applied for death benefits from the insurer, claiming his son was a dependant.

The arbitrator found that the son, who had a history of receiving welfare benefits, short-term jobs, and incarcerations, was not principally dependent for financial support on his father at the time of the accident.

The claim for death benefits was dismissed, but the applicant was awarded his expenses for the arbitration proceeding.

The applicant was injured in two separate motor vehicle accidents.

Following the second accident, the insurer paid weekly income benefits under section 12 of the Statutory Accident Benefits Schedule but later terminated them, claiming an overpayment and arguing the applicant should have been classified under section 13 as unemployed.

The arbitrator found the applicant retained his status as a self-employed person at the time of the second accident, qualifying him under section 12.

However, because he earned no income in the 52 weeks preceding the second accident, his benefits were calculated at the minimum rate of $185.60 per week.

The arbitrator dismissed the insurer's claim for repayment of the overpaid amount under section 27(1), finding the error was not attributable to the applicant but to the insurer's failure to make reasonable inquiries.

The applicant was awarded expenses.

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

The insurer terminated weekly and child care benefits on the basis that the applicant did not meet the stricter post-156 week eligibility test.

The arbitrator found that the applicant's primary debilitating condition, carpal tunnel syndrome, was unrelated to the accident.

The arbitrator concluded that the applicant's accident-related injuries did not continuously prevent her from engaging in substantially all of her normal activities.

The claims for ongoing weekly benefits, child care benefits, and supplementary medical and rehabilitation benefits were dismissed, though the applicant was awarded her arbitration expenses.

The applicant, a high school student injured in a motor vehicle accident, had a legitimate offer for a summer job at the time of the accident.

The insurer paid increased weekly benefits during the summer employment period but reduced them after the job would have ended.

The applicant sought to have the higher benefit rate continue indefinitely.

The arbitrator held that under section 12 of the Statutory Accident Benefits Schedule, the weekly benefit for an insured with a time-limited employment offer is based on the contract of employment only for the expected duration of that employment.

After the summer job period ended, the applicant's benefits were correctly reduced to the statutory minimum of $185.60 per week.

The applicant was awarded expenses due to the novel legal question.

The applicant applied for caregiver benefits under the Statutory Accident Benefits Schedule, claiming he quit his job to provide full-time care for his son who was injured in a motor vehicle accident.

The insurer had paid some benefits but later sought repayment, arguing the payments were made in error.

The arbitrator found that the son's injuries did not require full-time care beyond normal parental duties and that the applicant had quit his jobs for economic reasons, not to provide care.

The arbitrator dismissed the claim for additional benefits and ordered the applicant to repay $36,295.00 to the insurer, finding that the applicant had misled the insurer about his employment and caregiving status.

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

The applicant disputed the termination and applied for arbitration.

At the hearing, the applicant's representative requested an adjournment, which was denied due to a lack of reasonable grounds and a history of uncooperative behaviour, including failing to attend a pre-hearing discussion and medical examinations.

The applicant withdrew from the hearing.

The arbitrator heard evidence from the insurer, including medical reports indicating the applicant was exaggerating his disability.

The arbitrator dismissed the applicant's claim for ongoing benefits and denied his request for arbitration expenses.

The applicant was injured in a motor vehicle accident and received statutory accident benefits, which were later terminated by the insurer.

The applicant applied for mediation but walked out within five minutes of the meeting's commencement, refusing to participate.

The mediator issued a report stating that mediation did not take place.

The applicant then applied for arbitration.

The arbitrator held that the applicant was not entitled to proceed to arbitration because the statutory requirement to seek and fail at mediation requires meaningful participation in good faith, not merely filing forms and walking out.

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

The applicant sought ongoing benefits, claiming a hearing loss resulting from the accident prevented her from working as a waitress.

The arbitrator found the hearing loss was a pre-existing condition and dismissed the claim for ongoing benefits.

The insurer sought repayment of an overpayment, arguing the applicant's pre-accident income was misstated.

The arbitrator agreed, finding the applicant had no earnings in the four weeks prior to the accident, and ordered the applicant to repay the overpayment with interest.