Statutory Accident Benefits Schedule matters (SABS) - OFSCDRS

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

She applied for arbitration, claiming a substantial inability to perform the essential tasks of her pre-accident employment as a cook.

The arbitrator reviewed medical evidence, including functional capacity assessments and expert reports, which indicated she was capable of returning to work with minor restrictions.

Finding the applicant's testimony regarding her limitations lacked credibility and was inconsistent with her activities, the arbitrator concluded she did not suffer a substantial inability to perform her essential tasks and dismissed the claim for further benefits, though awarded her arbitration expenses.

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

The applicant sought arbitration for continued benefits, claiming she remained substantially unable to perform the essential tasks of her employment as a store manager.

The arbitrator found the applicant's evidence unreliable and preferred the results of a functional capacity evaluation which indicated she was capable of returning to work.

The arbitrator concluded the applicant was not substantially disabled and dismissed the claim for further income benefits, but awarded the applicant her expenses for the arbitration.

The applicant was injured when he slipped on ice while exiting his van.

The insurer denied his claim for statutory accident benefits on the basis that the injury was not caused by an 'accident' as defined in section 2 of the Statutory Accident Benefits Schedule.

The arbitrator applied the broad interpretation from the Supreme Court of Canada's decision in Amos, finding that exiting a vehicle is an ordinary and well-known activity to which automobiles are put, and that the use of the van contributed to the injury.

The arbitrator concluded that the applicant was injured in an accident and is eligible for benefits.

The insurer appealed a preliminary arbitration decision finding that the insured was not disentitled to weekly income benefits under section 16(2) of the Schedule, as she had not worked for a continuous period of 90 days after the two-year anniversary of the accident.

The insured appealed a subsequent arbitration decision finding she was no longer eligible for weekly income benefits under section 12(1).

The Director's Delegate dismissed both appeals, upholding the arbitrator's interpretation of section 16(2) as referring to continuous periods of work, and finding no error in the arbitrator's evaluation of the evidence regarding the insured's eligibility.

The insurer was ordered to pay the insured's expenses for the preliminary issue appeal, but no expenses were awarded for the eligibility appeal.

The applicant, on behalf of her minor daughter who suffered a spinal cord injury in a motor vehicle accident, sought statutory accident benefits for the purchase of a new home.

The insurer argued its obligation was limited under subsection 41(1) of the 1994 Schedule to the cost of renovating the daughter's 'existing home', which was a townhouse owned by her mother's estranged husband.

The arbitrator held that the townhouse was the 'existing home' despite the lack of ownership by the insured, and that the insurer's present obligation towards a new home was restricted to the value of the renovations that would have been required for the townhouse.

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

The insurer paid some initial chiropractic and travel expenses but denied further claims.

The applicant sought arbitration for supplementary medical rehabilitation expenses, weekly income benefits, and a special award.

The arbitrator allowed the claim for specific chiropractic treatments and associated travel expenses incurred in 1992, finding them reasonable and necessary.

However, claims for housekeeping expenses, herbal remedies, a spa, and weekly income benefits were dismissed due to a lack of medical evidence connecting them to the accident.

The request for a special award was also denied, as the insurer had not acted unreasonably.

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

The insurer terminated benefits, arguing the applicant no longer met the stricter disability test under section 12(5)(b) of the Statutory Accident Benefits Schedule.

The arbitrator found that while the applicant suffered from chronic back pain and might be disabled from his pre-accident heavy manual job, he failed to prove that his injuries continuously prevented him from engaging in any occupation or employment for which he was reasonably suited by education, training, or experience.

The application for further weekly income benefits was dismissed, but the insurer was ordered to pay the applicant's arbitration expenses.

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

The Applicant applied for arbitration regarding entitlement to weekly income benefits.

At a pre-hearing, the Insurer sought to add the issues of quantum and repayment of benefits to the arbitration, which the Applicant opposed.

The Arbitrator held that an arbitrator has jurisdiction under the Insurance Act and the Statutory Powers Procedure Act to add issues not raised by the applicant, provided they have been mediated, are reasonably incidental to the applicant's issues, and do not unduly expand the scope of the inquiry.

The Arbitrator found that quantum and repayment were reasonably incidental to the issue of entitlement and added them to the arbitration.

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

The applicant subsequently signed a release in exchange for a lump sum settlement of $9,500.

The applicant later sought further benefits, arguing he misunderstood the duration of his entitlement and would not have signed the release had he known benefits could continue past age 65.

The insurer denied further benefits, relying on the release.

In a preliminary issue hearing, the arbitrator found no fraud, misrepresentation, or other vitiating factor to set aside the settlement.

The arbitrator concluded the applicant entered into a final and binding settlement and could not proceed to arbitration.

The applicant was awarded expenses for the preliminary hearing.

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

The applicant sought reinstatement of benefits, claiming ongoing disability due to chronic neck and back pain.

The arbitrator found that while the applicant's pre-existing degenerative disc disease was aggravated by the accident, surveillance video demonstrating the applicant laying bricks showed he no longer had physical limitations preventing him from working.

The arbitrator concluded the applicant was entitled to benefits up to July 31, 1993, but failed to prove ongoing disability beyond that date.

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

The Insurer terminated weekly income benefits, but after mediation, the parties settled for a specific period and the Applicant signed a release.

The Insurer argued the release barred future claims and that the two-year limitation period had expired.

The Arbitrator found the release was confined to the specific period settled at mediation and did not bar future claims.

Furthermore, the limitation period had not begun to run because the Insurer failed to provide clear and unequivocal written notice of its refusal to pay benefits after the settlement, as required by the Schedule.

The Applicant was permitted to proceed to arbitration.

The applicant sought statutory accident benefits, including weekly income benefits and yard work expenses, following a 1991 motor vehicle accident.

The insurer had terminated weekly income benefits in 1992.

The arbitrator found that the applicant's ongoing disability was caused by a pre-existing arthritic condition and a prior 1989 accident, not the 1991 accident.

The applicant's evidence was deemed unreliable and contradictory.

The claims for weekly income benefits, yard work expenses, and a special award were dismissed.

Due to the applicant's failure to comply with production orders, disruptive behaviour at the hearing, and pursuit of a frivolous claim, the arbitrator ordered the applicant to pay the insurer's $1,000 assessment fee.

The applicant was injured in a motor vehicle accident while driving a taxicab.

He applied for statutory accident benefits from both the insurer of the taxicab and his personal automobile insurer.

The insurers disputed priority.

The arbitrator held that the applicant's personal insurer was responsible for paying the benefits, as the applicant was a named insured under his personal policy, and the priority rules under section 268 of the Insurance Act require an insured to look to their own insurer first, despite the commercial use exclusion in the personal policy.

The applicant, a self-employed taxi driver, was injured in a motor vehicle accident and sought statutory accident benefits.

The insurer denied transportation expenses because the applicant paid a friend to drive him, and paid only the minimum weekly income benefits, arguing the applicant lacked sufficient financial records.

The arbitrator ordered the insurer to pay the transportation expenses, finding them reasonable and required.

The arbitrator also ordered the insurer to pay weekly income benefits based on the applicant's trip sheets, finding them to be the best evidence of income for a cash business, resulting in an award for the underpaid amount.

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

The insurer terminated benefits, arguing she did not meet the post-156 week disability test under section 12(5)(b) of the Statutory Accident Benefits Schedule.

The arbitrator found that while the applicant was reasonably suited for light assembly work or her pre-accident work as a motor repair technician, she required a graduated work hardening program to build up her working tolerance before returning to full-time employment.

The arbitrator ordered the insurer to pay ongoing weekly income benefits until the completion of the recommended work hardening program.

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

The Applicant sought ongoing benefits, while the Insurer sought repayment of benefits paid, alleging fraud.

The arbitrator found that the Applicant was capable of working in his family cleaning business and had exaggerated his injuries, as evidenced by surveillance video and inconsistent testimony.

The arbitrator concluded the Applicant did not suffer a substantial inability to perform his essential tasks and ordered him to repay $36,474.84 in benefits obtained through fraud.

The applicant was injured in a motor vehicle accident while a passenger in a vehicle insured by Lambton Mutual.

The applicant had no personal motor vehicle insurance.

Lambton Mutual argued its policy was void ab initio due to material misrepresentations by the named insured regarding ownership and principal driver status, and claimed General Accident (the insurer of the other vehicle) should pay the statutory accident benefits.

The arbitrator found that while there was material misrepresentation, the defence of void ab initio is not available against an innocent third party claiming statutory accident benefits, pursuant to section 233(2) of the Insurance Act.

Lambton Mutual was held liable to pay the benefits.

The applicant sought an assessment of expenses following an arbitration hearing where her claim for additional benefits was denied but the insurer was ordered to pay her arbitration expenses.

The parties disputed three items: an expert witness fee, a psychiatrist's report and consultation fee, and the cost of clinical notes.

The arbitrator allowed the expert witness fee at a reduced hourly rate for the day she testified, denied the psychiatrist's fees as unnecessary, and allowed the cost of the clinical notes as they were produced at the insurer's request.

The applicants, family members of a deceased motor vehicle accident victim residing in Ethiopia, brought a motion for an interim award of expenses to fund their travel to Ontario for an arbitration hearing regarding death benefits.

The arbitrator applied the criteria for interim expenses, requiring the applicants to demonstrate a case of sufficient merit.

Finding that the applicants provided minimal and unsupported evidence regarding their dependency on the deceased, the arbitrator concluded they failed to establish a bona fide issue.

The motion for interim expenses was dismissed.

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

He returned to work full-time for nearly six months before stopping due to chronic pain, and sought reinstatement of his weekly income benefits and vocational retraining.

The insurer argued that returning to work for more than 90 days after the two-year anniversary of the accident precluded further benefits under section 16(2) of the Schedule.

The arbitrator held that section 16(2) creates a rebuttable presumption of ineligibility, which the applicant successfully rebutted with medical evidence showing he was substantially disabled from his essential tasks.

The applicant was awarded weekly income benefits up to the 156-week mark and vocational retraining costs, but was denied benefits beyond 156 weeks as he failed to prove he was continuously prevented from engaging in any suitable occupation.