Statutory Accident Benefits Schedule matters (SABS) - OFSCDRS

The appellant was injured in a snowmobile accident and received statutory accident benefits until they were terminated by the insurer.

An arbitrator dismissed his claims for ongoing weekly benefits, primary caregiver benefits, and expenses for various goods and services, but awarded him arbitration expenses.

The appellant appealed the arbitrator's findings on his inability to perform essential tasks, and the insurer cross-appealed the award of expenses.

The Director of Arbitrations dismissed both the appeal and cross-appeal, finding that the arbitrator applied the correct legal tests, made factual findings supported by the evidence, and appropriately exercised discretion in awarding expenses.

The insurer appealed an arbitration order awarding the claimant $3,720 for babysitting and housekeeping services under paragraph 6(1)(f) of the Statutory Accident Benefits Schedule.

The insurer argued that because the claimant was already receiving weekly benefits as an unemployed primary caregiver under section 13, he was precluded from recovering replacement services under section 6.

The Director of Arbitrations dismissed the appeal, holding that receipt of section 13 benefits does not foreclose recovery of supplementary care benefits under section 6, provided the expenses relate to the insured person's own needs.

The Director also declined to interfere with the arbitrator's factual findings regarding the apportionment of the housekeeper's duties.

The respondent was injured in a motor vehicle accident while vacationing in Vietnam.

She applied for statutory accident benefits under a standard motor vehicle liability policy issued by the appellant.

The appellant denied the claim on the basis that the policy applies only to accidents in Canada, the United States, or on a vessel travelling between the ports of those countries.

An arbitrator initially held that the Statutory Accident Benefits Schedule operated without territorial limitation.

On appeal, the Director of Arbitrations allowed the appeal, finding that the Schedule does not operate independently of the contract of insurance, which contains a valid territorial limitation.

The respondent was therefore not eligible to receive benefits for the accident in Vietnam.

The applicant was injured in two motor vehicle accidents and received statutory accident benefits until the insurer terminated them.

The applicant applied for arbitration to claim ongoing weekly income benefits.

The arbitrator found the applicant's evidence regarding his pre-accident medical condition and employment status lacked credibility, noting significant pre-existing back and neck issues.

The arbitrator concluded the applicant failed to establish the essential tasks of his pre-accident employment and failed to prove his current medical difficulties were causally related to the motor vehicle accidents.

The claim for ongoing benefits was dismissed, but the applicant was awarded one-half of his arbitration expenses.

The appellant was injured in a motor vehicle accident but did not submit an application for statutory accident benefits until more than two years later.

The insurer denied the claim as out-of-time.

The appellant argued the insurer waived or was estopped from relying on the time limits because it failed to provide an application form, investigated the late claim, and obtained medical information without a non-waiver agreement.

The Director's Delegate upheld the arbitrator's decision, finding no intentional relinquishment of rights by the insurer and no detrimental reliance by the appellant.

The appeal was dismissed and expenses were denied.

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

The applicant applied for arbitration, claiming ongoing weekly income benefits on the basis that severe, unpredictable headaches caused by the accident continuously prevented him from engaging in any occupation for which he was reasonably suited.

The Arbitrator found the applicant credible and accepted medical evidence that his severe headaches were debilitating and unpredictable.

The Arbitrator concluded that the applicant was continuously prevented from engaging in suitable employment and ordered the insurer to pay ongoing weekly income benefits and arbitration expenses.

The Applicant was injured in a motor vehicle accident while driving a taxi in the course of his employment.

He applied for statutory accident benefits from Allstate, which insured his personal vehicle.

Allstate argued that Wellington, which insured the taxi, was responsible.

The arbitrator determined that the Applicant was an 'insured person' under the Allstate policy and not a 'named insured' under the Wellington policy.

Therefore, Allstate was held responsible for paying the Applicant's statutory accident benefits.

The Arbitrator issued a correction to a previous decision dated June 24, 1996.

The correction amended the interest rate awarded to the applicant from 2% per annum to 2% per month on any outstanding amounts.

The applicant was injured in a motor vehicle accident while participating in a workers' compensation retraining program.

He claimed ongoing weekly income benefits under section 12 or 13 of the Statutory Accident Benefits Schedule.

The arbitrator found that the applicant was not employed by the Workers' Compensation Board and did not qualify under section 12.

However, the arbitrator concluded that the applicant suffered a substantial inability to perform his essential tasks as a student due to chronic pain and reflex sympathetic dystrophy, entitling him to ongoing benefits under section 13.

The claim for a special award was dismissed for lack of jurisdiction as it had not been mediated.

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

The insurer terminated weekly income benefits and sought repayment, alleging material misrepresentation regarding vehicle ownership and the applicant's driving record.

The arbitrator found the applicant's evidence regarding his disability and income to be wholly unreliable and contradictory.

The arbitrator concluded that the insurance contract was obtained through material misrepresentation, precluding the applicant from receiving weekly income benefits.

The applicant was ordered to repay all weekly income benefits received and to pay the insurer's assessment costs due to his frivolous, vexatious, and abusive conduct throughout the proceedings.

The applicant was involved in two motor vehicle accidents and received weekly income benefits from the insurer.

The insurer terminated benefits, alleging the applicant was no longer disabled and had post-accident earnings resulting in an overpayment.

The arbitrator found the applicant failed to establish a substantial inability to perform her essential tasks after the termination date, relying on surveillance evidence and the unreliability of her testimony.

The arbitrator recalculated the benefit amounts and determined the insurer had overpaid the applicant by $14,664 due to a failure to deduct post-accident income.

However, the arbitrator declined to order repayment, finding the overpayment resulted primarily from the insurer's own adjusting errors rather than the applicant's misrepresentations.

The insured person committed suicide by carbon monoxide poisoning in his parked car.

His widow applied for death and funeral benefits under his automobile insurance policy.

The insurer denied the claim on the basis that suicide is not an 'accident' under the Statutory Accident Benefits Schedule.

The arbitrator found in favour of the widow, concluding that the definition of 'accident' in the Schedule was broad enough to include suicide.

On appeal, the Director's Delegate reversed the arbitrator's decision, holding that the definition of 'accident' restricts rather than expands the common law meaning, and does not include intentional acts such as suicide.

The appeal was allowed and the claim for benefits was dismissed.

The appellant insurer appealed an arbitration decision finding it responsible for paying the respondent pedestrian's accident benefits.

The pedestrian was struck by a vehicle insured by the appellant.

She applied for benefits under a policy held by her former common-law partner, insured by the respondent insurer.

The arbitrator found that the pedestrian and the named insured were not spouses at the time of the accident because they had ceased cohabiting for over a year.

On appeal, the Director's Delegate upheld the decision, finding that a temporal connection is implicit in the definition of "spouse" under the Insurance Act and the standard automobile policy, and that non-married spousal status ends when the parties cease to cohabit in a relationship of some permanence.

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

She applied for ongoing weekly income benefits, arguing she suffered from post-concussion syndrome and a brain injury that prevented her from working.

The insurer argued her inability to work was due to pre-existing psychological conditions and post-accident life events.

The arbitrator found that the accident materially contributed to her disability, exacerbating a pre-existing personality disorder, and that she was continuously prevented from engaging in suitable employment.

The arbitrator also ordered a $5,000 special award against the insurer for unreasonably terminating and withholding benefits based on a cursory neurological report while ignoring numerous other medical recommendations.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits, including weekly income benefits, transportation expenses, and chauffeur/companion expenses for her husband.

The arbitrator found that the applicant, who worked in her husband's family business, did not suffer a substantial inability to perform the essential tasks of her employment and denied the weekly income benefits.

The claim for an increased transportation allowance was dismissed for lack of proof.

However, the arbitrator allowed the claim for chauffeur/companion expenses for out-of-town medical appointments, awarding 108 hours at the minimum wage rate.

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

The Insurer reduced and later terminated his weekly income benefits, alleging an overpayment.

The Applicant sought arbitration, claiming his benefits should be based on a $2,400 cash contract he allegedly performed in the four weeks prior to the accident.

The arbitrator found the Applicant lacked credibility and failed to provide objective evidence of the alleged contract or earnings.

The arbitrator concluded the Applicant fabricated the contract to inflate his benefits, set the weekly income benefit at the minimum rate of $185.60, and denied the Applicant his expenses.

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

The applicant applied for arbitration, claiming ongoing entitlement under section 12(5)(b) of the Statutory Accident Benefits Schedule.

The arbitrator found that the applicant suffered from chronic pain syndrome resulting from the accident, which continuously prevented him from engaging in any employment for which he was reasonably suited by education, training, or experience, including the alternative position of a service advisor.

The arbitrator ordered the insurer to pay weekly income benefits from the date of termination, along with interest and arbitration expenses.

The applicant sought ongoing weekly income benefits following a motor vehicle accident but failed to attend the arbitration hearing.

The arbitrator proceeded in his absence under the Statutory Powers Procedure Act.

The applicant failed to meet his burden of proof, and the arbitration was dismissed.

The arbitrator found the proceeding to be an abuse of process and awarded the insurer $2,000 in expenses under the Insurance Act.

The insurer appealed an arbitration order finding that the insured's application for arbitration was not statute-barred.

The insurer argued that it had mailed a notice of refusal to pay benefits, triggering the two-year limitation period under the Insurance Act.

The Director of Arbitrations dismissed the appeal, finding insufficient evidence that the notice of refusal ever left the insurer's internal mail system or was received by the insured.

As a result, the limitation period had not commenced, and the insured's application was allowed to proceed.

The insurer brought a motion to dismiss the insured's application for arbitration and for payment of its $1,000 assessment, arguing the insured's conduct constituted an abuse of process.

The insured's counsel had requested an adjournment but subsequently failed to coordinate a new hearing date or respond to numerous communications from the Commission and the insurer over a six-month period.

The arbitrator found that the unexplained failure to respect the Commission's procedures and respond to inquiries constituted an abuse of process.

However, the arbitrator declined to dismiss the arbitration, instead ordering the insured to pay the insurer's $1,000 assessment as a condition of proceeding with a rescheduled hearing.