Statutory Accident Benefits Schedule matters (SABS) - OFSCDRS

The applicant was partially successful in her claim for statutory accident benefits, recovering less than the insurer's pre-hearing settlement offer.

The insurer argued it should be awarded its expenses because its offer exceeded the recovery.

The arbitrator rejected a strict results-based approach but noted the applicant had sufficient guidance from prior decisions to evaluate the offer.

The arbitrator exercised discretion to award the applicant half of her arbitration expenses, totaling $1,500.

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

Zurich brought a preliminary motion arguing it had an absolute defence under the Disputes Between Insurers Regulation, alleging that another insurer, Lumbermens, was the first to receive a completed application for benefits.

The arbitrator found that Zurich's evidence was based on unsupported hearsay, while documentary evidence from Lumbermens refuted the claim that it had received an application.

The arbitrator concluded that Zurich received the first completed application and dismissed the motion, allowing the applicant to proceed to arbitration against Zurich.

The insurer brought a preliminary motion seeking to compel the insured to attend psychiatric and neuropsychological assessments under section 42 of the Statutory Accident Benefits Schedule.

The insured opposed the motion, arguing the request was not reasonably necessary and was made too close to the scheduled arbitration hearing.

The arbitrator found that while earlier medical recommendations provided a reasonable basis for the assessments, the insurer's delay of over two years in arranging them was unreasonable and prejudicial to the insured.

The arbitrator also rejected the insurer's argument that a recent psychiatric report raised a new diagnosis warranting fresh assessments.

The motion was dismissed.

The moving party, counsel of record for the applicant, brought a motion to be removed as solicitor of record due to an alleged breakdown in the solicitor-client relationship.

The applicant opposed the motion.

The arbitration had been delayed for years due to concerns regarding the applicant's capacity to instruct counsel, and the moving party's law firm had previously undertaken to have a litigation guardian appointed but failed to do so.

The arbitrator found that the moving party failed to fulfill a subsequent undertaking to produce medical evidence addressing the applicant's capacity.

Given the ongoing ambiguity regarding capacity, the failure to abide by undertakings, and the prejudice to the applicant, the arbitrator declined to exercise discretion to release the moving party as solicitor of record and adjourned the matter for the production of medical evidence.

The appellants appealed an arbitrator's preliminary decision that deferred the determination of whether third-party representatives could be ordered to pay the insurer's arbitration expenses.

The Director's Delegate rejected the appeal as premature under Rule 51.2 of the Dispute Resolution Practice Code, finding that the arbitrator had not yet made a final order for the payment of expenses and that acknowledging the appeal would cause the parties to incur additional unrecoverable expenses.

The applicant sought statutory accident benefits after falling while alighting from a TTC bus.

The insurer denied benefits, arguing the fall was not directly caused by the use or operation of an automobile.

The arbitrator found the applicant's testimony credible that she misjudged the distance from the bottom step to the pavement, lost her balance, and stumbled before falling.

The arbitrator concluded the incident met the definition of an accident under section 2(1) of the Schedule, as the use or operation of the bus directly caused the impairment.

A partner at a treatment centre commenced arbitration applications for statutory accident benefits in the names of two former patients.

The patients had previously settled their claims and paid the treatment centre's account in full.

The arbitrator found that the authorizations filed by the treatment provider were forged and that the patients had not authorized the proceedings.

Finding that the treatment provider commenced the arbitration on his own account and abused the tribunal's process, the arbitrator amended the style of cause to make the provider the applicant and ordered him to pay the expenses of the patients and the insurer before being permitted to withdraw the applications.

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

The insurer refused to pay, raising a preliminary issue that the applicant made a material misrepresentation on her insurance application by failing to disclose her complete accident history.

The arbitrator found that the applicant knowingly failed to disclose prior accidents, which constituted a material misrepresentation that induced the insurer to enter into the contract.

Pursuant to section 30(2)(a) of the Statutory Accident Benefits Schedule, the insurer was relieved of its obligation to pay the claimed benefits.

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

The insurer argued the appellant's subsequent application for arbitration was time-barred under the two-year limitation period.

Applying the Supreme Court of Canada's decision in Smith v. Co-operators General Insurance Co., the Director's Delegate found that the insurer's termination notice was deficient because it failed to inform the appellant of the right to sue or arbitrate if mediation failed.

Consequently, a valid refusal was not given, the limitation period was not triggered, and the appellant's right to arbitrate was not barred.

The applicant's son was killed in a motor vehicle accident when he was struck as a pedestrian by a vehicle insured by the respondent.

The applicant, who lived in Ethiopia, claimed entitlement to death benefits under section 25 of the Statutory Accident Benefits Schedule, arguing she was principally dependent on her son for financial support.

The insurer disputed the dependency claim, questioning the sufficiency of the evidence provided, which included a decision from an Ethiopian communal court and a statutory declaration.

The arbitrator found that the applicant had made best efforts to provide the requested information and that the evidence, including the Ethiopian court decision, established she was financially dependent on her son.

The arbitrator ordered the insurer to pay $35,000 in death benefits plus interest.

The applicant applied for statutory accident benefits following a motor vehicle accident and subsequently applied for arbitration at the Financial Services Commission of Ontario.

At the scheduled hearing, the applicant failed to attend and was unrepresented.

The arbitrator dismissed the application for arbitration due to the applicant's non-attendance and ordered the applicant to pay $500.00 in expenses to the insurer.

The insurer brought a preliminary motion to dismiss the arbitration because the applicant failed to comply with a prior order to pay $500 in expenses.

The applicant argued she was unable to pay because the insurer had not paid any benefits.

The arbitrator ordered that the arbitration be stayed until the applicant complies with the prior order.

The insurer brought a motion to dismiss the arbitration because the applicant failed to comply with a prior order to pay $500 in expenses.

The applicant argued that he was unable to pay because the insurer had not paid any benefits.

The arbitrator ordered that the arbitration be stayed until the applicant complies with the prior order.

The insurer appealed an arbitration decision reinstating the insured's income replacement benefits, arguing the Arbitrator failed to apply the 'crumbling skull' rule to the insured's pre-existing heart condition.

The Director's Delegate dismissed the appeal, finding the Arbitrator correctly applied the 'significant or material contribution' test from Athey v. Leonati.

The Arbitrator's factual finding that the insured's heart condition did not deteriorate significantly after the accident and did not impact his functional ability was supported by the evidence and not reviewable as an error of law.

The insurer brought a motion to compel the applicant, an 11-year-old boy whose mother was killed in a motor vehicle accident, to attend an insurer's medical examination with a psychologist and to compel production of his treating psychologist's clinical notes and records.

The applicant brought a cross-motion for payment of a psychological report.

The parties resolved the examination and production issues on consent.

The arbitrator dismissed the applicant's motion for payment of the report as premature, noting that the invoice had not yet been submitted to the insurer.

The insurer brought a motion seeking to conduct an examination for discovery of the applicant and her treatment provider regarding the nature and medical benefits of a disputed treatment.

The arbitrator dismissed the motion, finding that the insurer had already received significant documentary disclosure and that ordering an oral examination for discovery would be a significant and inappropriate departure from the Commission's pre-hearing disclosure process.

The applicant, who sustained a closed head injury in a motor vehicle accident, applied for statutory accident benefits.

A preliminary issue hearing was held to determine whether the applicant had the mental capacity to proceed in the dispute resolution process and, if not, whether his son should be appointed to act on his behalf.

The arbitrator found that the applicant lacked the mental capacity to proceed, relying on capacity assessments and the applicant's demeanor at the hearing.

The arbitrator appointed the applicant's son to proceed in the dispute resolution process and to receive and administer statutory accident benefits on his behalf.

The applicant sought income replacement benefits, non-earner benefits, and medical expenses following a motor vehicle accident.

The arbitrator found that the applicant fabricated his pre-accident employment and was therefore not entitled to income replacement benefits.

The claim for non-earner benefits was dismissed as the applicant failed to prove a complete inability to carry on a normal life.

The arbitrator also held that the applicant's failure to attend a Designated Assessment Centre (DAC) barred him from recovering medical expenses incurred after the scheduled assessment date, but he was entitled to reasonable and necessary expenses incurred prior to that date.

The applicant commenced an arbitration for $3,300 in medical assessments following a motor vehicle accident.

At the hearing, her counsel requested an adjournment and production orders, which were denied, and then left the hearing.

The application was subsequently dismissed.

The insurer sought expenses and an award under s. 282(11.2) of the Insurance Act.

The arbitrator found the proceeding was an abuse of process and ordered the applicant to pay $1,000 in expenses and a $3,000 award to the insurer.

The applicant sought statutory accident benefits for acupuncture treatment following a motor vehicle accident.

The applicant failed to attend the arbitration hearing, and her representative successfully moved to withdraw from the record due to a loss of contact.

In the absence of any supporting evidence, the arbitrator dismissed the applicant's claims.

The insurer's request for the return of its assessment fee under s. 282(11.2) of the Insurance Act was denied, as the application was not shown to be frivolous or an abuse of process when commenced, but the insurer was awarded $1,500 in hearing expenses.