Statutory Accident Benefits Schedule matters (SABS) - OFSCDRS

The insurer appealed a preliminary arbitration decision finding that the insured's claim for caregiver benefits was not time-barred.

The central issue was whether the two-year limitation period for applying for mediation under the Insurance Act and the SABS-1994 commenced upon the insurer's initial notice of intention to terminate benefits or upon the release of the Designated Assessment Centre (DAC) report.

The Director's Delegate held that when an insured requests a DAC assessment, the insurer's 'refusal to pay' does not occur until the DAC report is released and the insurer is authorized to stop paying benefits.

Consequently, the limitation period had not expired, and the appeal was dismissed.

The applicant sought statutory accident benefits following a series of altercations and collisions with another driver that began in a car wash.

The arbitrator found that while the initial collisions were 'accidents' under the Schedule, the subsequent physical assault and the applicant's intentional ramming of the other vehicle were not.

The application was dismissed because the applicant, who was repeatedly disruptive and abusive during the hearing, failed to provide credible evidence of disability, causation, or income loss.

The arbitrator concluded the hearing early due to the applicant's contemptuous and abusive behaviour, which constituted an abuse of process.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits for case management services.

After mediation failed, the applicant commenced a court action claiming medical and rehabilitation benefits, and subsequently applied for arbitration at the Financial Services Commission of Ontario for the same benefits.

The insurer argued the arbitration was an abuse of process due to the pre-existing court action.

The arbitrator dismissed the arbitration, finding the court action was commenced first and was more comprehensive in scope.

The arbitrator also found the arbitration was frivolous, vexatious, and an abuse of process from the outset, ordering the applicant to pay the insurer's $3,000 assessment and $510 in arbitration expenses.

The applicant sought statutory accident benefits following a series of incidents that began with a minor collision in a car wash, escalated to a physical assault by the other driver, and culminated in the applicant intentionally ramming the other driver's vehicle under a tractor-trailer.

The arbitrator found that while the initial collisions were 'accidents' under the Schedule, the assault and the intentional ramming were not.

The application for weekly income benefits was dismissed because the applicant, who repeatedly disrupted the hearing and abused the process, failed to provide credible evidence of disability, causation, or income.

The hearing was ultimately concluded early due to the applicant's abusive and contemptuous behaviour.

Following an arbitration regarding statutory accident benefits where the applicant was awarded a small portion of the claimed death benefits, both parties sought their expenses.

The arbitrator considered the criteria under the Insurance Act and Regulation 664, including the applicant's lack of success, the conduct of both parties, and the complexity of the issues.

The arbitrator concluded that neither party was entitled to their expenses, ordering each party to bear their own costs.

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

Less than three weeks before the arbitration hearing, the insurer requested that the applicant attend an insurer's medical examination (IE) with an orthopaedic surgeon in Toronto.

The applicant, who lived in Port Dover, refused to attend on short notice.

The arbitrator held that the insurer's request was unreasonable, finding that the insurer had delayed requesting the IE for over five years without adequate justification.

The arbitrator concluded that allowing the late request would amount to trial brinkmanship and unfairly prejudice the applicant by likely necessitating an adjournment of the hearing.

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

The insurer terminated the benefits, and the applicant applied for arbitration.

The insurer raised a preliminary issue that the application was filed beyond the two-year limitation period under section 281(5) of the Insurance Act and section 72(1) of the Statutory Accident Benefits Schedule.

The arbitrator found that the insurer failed to provide the required notice under section 64 of the Schedule before terminating benefits, and that its initial letter did not constitute a clear and unequivocal refusal.

Therefore, the limitation period had not expired, and the applicant was not precluded from proceeding to arbitration.

Following an arbitration decision regarding statutory accident benefits where the applicant had mixed success, the parties sought a determination on expenses.

The insurer argued the applicant should only receive half his expenses because he was unsuccessful on the income replacement benefit claim.

The arbitrator awarded full expenses to the applicant, finding that the insurer's procedurally defective adjustment of the medical and rehabilitation claims justified a full award despite the applicant's lack of complete success.

The applicant, who suffered paraplegia in a motor vehicle accident, applied for statutory accident benefits.

The arbitrator found that the applicant was entitled to weekly income benefits post-156 weeks because her injuries continuously prevented her from engaging in substantially all of her pre-accident activities.

The arbitrator also awarded care benefits of $250 per week, finding that her husband reasonably lost this gross income in caring for her.

Claims for a new wheelchair, shower modifications, and counselling were granted as reasonable and necessary rehabilitation expenses, while claims for a new home, a modified van, and a power scooter were denied.

The applicant's request for a special award was dismissed as the insurer's conduct was not found to be unreasonable.

The applicant was injured in a motor vehicle accident and received income replacement benefits before returning to her pre-accident employment.

She claimed entitlement to a Loss of Earning Capacity (LEC) offer, arguing she was physically unable to take better post-accident employment opportunities due to the accident.

The arbitrator held that under the Statutory Accident Benefits Schedule, continuing entitlement to income replacement benefits at the two-year mark is based on the employment the applicant was engaged in at the time of the accident.

Since she had returned to her pre-accident employment, she was not entitled to an LEC offer based on prospective employment opportunities.

The applicant was injured in a motor vehicle accident and received weekly income replacement benefits until the insurer terminated them at the 156-week mark.

The insurer argued the applicant could return to work in a suitable occupation, such as a millwright foreman.

The arbitrator found that the applicant had developed a chronic pain syndrome as a result of the accident, which caused fluctuating symptoms, fatigue, and poor endurance.

Applying the post-156 week test, the arbitrator concluded that the applicant's condition continuously prevented him from engaging in any occupation or employment for which he was reasonably suited, including part-time sedentary work.

The insurer was ordered to pay ongoing weekly income replacement benefits and interest.

The applicant was injured in a motor vehicle accident and reported it to the insurer two days later.

The insurer mailed an application package, but the applicant did not submit it until over nine months after the 90-day time limit expired.

The applicant claimed he was unaware of the time limit because the explanation form was missing from his package.

The arbitrator rejected this argument, finding it implausible that the insurer removed the form and noting the applicant's lack of medical treatment or follow-up.

The arbitrator concluded the applicant failed to demonstrate a reasonable excuse for the delay, and the claim for accident benefits was dismissed.

The applicant was injured in a motor vehicle accident and claimed statutory accident benefits, including income replacement and housekeeping expenses, arguing she could no longer work as a live-in housekeeper.

The arbitrator found that while the applicant sustained genuine injuries, including vertigo and cervicogenic pain, she exaggerated her limitations and was only disabled from working until her employer returned from Florida on February 21, 1996.

Income replacement benefits were awarded up to that date, along with a 50% special award because the insurer unreasonably withheld payment despite having uncontradicted medical evidence of disability for that initial period.

Claims for ongoing income replacement, housekeeping, and a case manager were dismissed.

The insurer brought a motion for interim expenses against the applicant due to the conduct of the applicant's counsel.

The applicant's counsel failed to attend a scheduled pre-hearing discussion without a reasonable excuse and failed to comply with undertakings to produce medical authorizations and an OHIP summary within the required timelines.

The arbitrator found that the counsel's conduct prejudiced the insurer and frustrated the Commission's mandate to facilitate settlement.

The arbitrator ordered the applicant to pay $300 in interim expenses to the insurer, noting that the award should ideally be paid personally by the counsel.

The applicant was injured in a motor vehicle accident and received weekly income benefits before returning to full-time work as a campus police officer.

She continued to miss occasional days of work due to ongoing symptoms and claimed income benefits for those days, as well as for a three-week period following a physiotherapy program.

The arbitrator found that while the applicant was substantially unable to perform the essential tasks of her employment on the occasional days missed, the deduction of 80 percent of her post-accident income under section 15 of the Schedule reduced the payable benefit to zero.

The arbitrator also found the applicant was not disabled during the three-week period in December 1997 and dismissed the claim for a special award, concluding the insurer had not acted unreasonably.

The applicant sought statutory accident benefits, claiming he was an occupant of an insured vehicle involved in a collision.

The insurer denied benefits on the basis that the applicant was not an occupant of the vehicle at the time of the accident.

The arbitrator found the applicant's evidence to be inconsistent and unreliable, and preferred the evidence of the third-party driver and the insurer's accident reconstruction experts.

The arbitrator concluded that the applicant was not an occupant of the vehicle and therefore not an insured person entitled to benefits.

The application was dismissed, and the applicant was ordered to pay $3,000 to the insurer for commencing a frivolous and vexatious arbitration.

The applicant was injured in a motor vehicle accident and applied for statutory accident benefits, including caregiver benefits, housekeeping expenses, and the cost of an occupational therapy assessment.

The insurer denied the claims.

At arbitration, the arbitrator found that the applicant did not meet the "substantial inability" test for caregiver or housekeeping benefits, as she had returned to work and caregiving shortly after the accident with only minor residual complaints.

However, the arbitrator ordered the insurer to pay for the occupational therapy assessment, finding it was a reasonable expense and not subject to the conflict of interest disclosure provisions of section 38 of the Schedule.

The applicant's claim for a special award was dismissed.

The applicant failed to attend a scheduled preliminary hearing regarding his entitlement to caregiver benefits following a motor vehicle accident.

The insurer sought to have the application dismissed.

The arbitrator found that the applicant's failure to attend was excusable due to his undisputed psychiatric condition and lack of a fixed address, which likely resulted in him not receiving actual notice of the hearing.

The application was not dismissed, and the preliminary hearing was adjourned.

The issue of expenses was deferred to the hearing arbitrator.

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

The insurer terminated caregiver benefits and scheduled a medical examination.

The applicant attended but refused to proceed unless she could tape record the examination, alleging the doctor had been rude previously.

The doctor refused to proceed with the tape recorder.

On a preliminary motion, the arbitrator applied the principles from Bellamy v. Johnson and held that the applicant's refusal to submit to the examination without a tape recorder was unreasonable, as she failed to demonstrate a bona fide concern or propose safeguards to ensure the recording's reliability.

The applicant was injured while a passenger on a TTC streetcar.

She did not notify her husband's insurer of her intention to apply for accident benefits until 11 months after the accident, well past the 30-day requirement under section 59 of the Statutory Accident Benefits Schedule.

The insurer denied the claim due to late notice.

The applicant argued she had a reasonable excuse because her husband, fearing increased premiums, refused to provide his insurance details despite her repeated requests.

The arbitrator found that the applicant's excuse was reasonable given the family's patriarchal dynamic and her inability to obtain the information otherwise.

The insurer's motion to dismiss the claim was denied, allowing the applicant to proceed to arbitration on the merits.