Ontario Financial Services Commission - Dispute Resolution Services

The applicant was injured in a motor vehicle accident and sought a determination of catastrophic impairment under the Statutory Accident Benefits Schedule.

The arbitrator found that the applicant sustained a catastrophic impairment under both the 55% whole person impairment (WPI) threshold (clause 2(1.2)(f)) and the marked impairment threshold for mental or behavioural disorders (clause 2(1.2)(g)).

The arbitrator accepted the applicant's physical impairment rating of 48% WPI and assessed her mental and behavioural impairment at 33% WPI, resulting in a combined 65% WPI.

The arbitrator also found a marked impairment in three of four functional spheres.

Regarding the claimed expenses totaling $83,417.90, the arbitrator awarded only $1,925.00 for a mental health assessment, dismissing the remainder because they were not properly submitted through the HCAI system as required by the Schedule.

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

After the applicant passed away, her legal counsel was removed from the record as no Estate Trustee had been appointed to provide instructions.

The insurer brought a motion to dismiss the arbitration application.

As no one appeared or responded on behalf of the applicant's estate, the arbitrator found that continuing the proceeding would be an abuse of process.

The application for arbitration was dismissed without costs.

Following an arbitration where the applicant withdrew all issues except the cost of catastrophic impairment assessments, and the arbitrator ruled in favour of the insurer on that remaining issue, the insurer sought its expenses of the arbitration.

The insurer claimed $23,931.42 in fees and disbursements.

The arbitrator found that the insurer was successful, as the applicant withdrew the catastrophic impairment issue shortly before the hearing and lost on the assessment cost issue.

However, the insurer's claimed expenses were excessive and lacked supporting documentation for disbursements.

Taking a pragmatic approach, the arbitrator awarded the insurer $1,500.00 inclusive of fees, disbursements, and taxes.

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

After a dispute over terminated benefits, the parties reached a tentative settlement during the cooling-off period.

However, a misunderstanding arose due to an error by the insurer regarding a lump sum payment, leading the applicant to rescind the settlement and refuse to instruct his counsel.

At the arbitration hearing, the applicant did not appear but sent his nephew to request an adjournment and subsequently a withdrawal of the application.

The arbitrator allowed the application to be withdrawn without prejudice, noting the insurer's error contributed to the misunderstanding.

No expenses were awarded to either party.

The insurer appealed the Arbitrator's finding that the insured sustained a catastrophic impairment, arguing the Arbitrator applied the wrong causation test.

The insured cross-appealed the denial of Non-Earner Benefits, Housekeeping, and Attendant Care Benefits.

The Director's Delegate held that the 'but for' test, not the 'material contribution' test, is the correct causation test in accident benefits cases.

The Delegate found the Arbitrator misapprehended critical evidence regarding both the catastrophic impairment and Non-Earner Benefits claims, and remitted those issues for re-hearing.

The denial of Housekeeping and Attendant Care Benefits was upheld as the Arbitrator reasonably found the expenses were not incurred.

The appellant's legal representative, McLeish Orlando LLP, brought a motion to be removed from the record, citing a material breakdown in communications and a loss of confidence.

The appellant opposed the motion, arguing that she had not lost confidence in her lawyer and wished for the firm to continue representing her.

The Director's Delegate found that the solicitor-client relationship had irrevocably broken down, as the appellant's own statements demonstrated a lack of confidence in her lawyer's advice and competence.

The motion to withdraw was granted.

The Applicant was injured in a motor vehicle accident and sought income replacement benefits (IRBs) and medical benefits from the Insurer.

The Insurer terminated IRBs and denied certain treatment plans.

The Arbitrator found that the Applicant suffered from chronic pain and was substantially unable to perform the essential tasks of his pre-accident employment, and completely unable to engage in any reasonably suited employment post-104 weeks, entitling him to ongoing IRBs.

The Arbitrator also approved the disputed medical benefits and the cost of an OCF-3 certificate.

Furthermore, the Arbitrator ordered the Insurer to pay a special award of 50% of the outstanding IRBs and interest, finding that the Insurer had unreasonably withheld payments by failing to assess quantum or pay IRBs despite the Applicant's eligibility.

The applicant was struck by a police vehicle while walking in a parking lot and sought non-earner benefits and medical benefits under the Statutory Accident Benefits Schedule.

The insurer denied the claims, arguing the applicant's impairments stemmed from a prior 2010 motor vehicle accident and a physical assault that occurred immediately before the 2011 accident.

The arbitrator found that the applicant failed to establish that the 2011 accident caused an impairment that continuously prevented him from engaging in substantially all of his pre-accident activities.

The arbitrator noted the applicant's expert admitted his diagnosis might have changed had he known about the applicant's prior chronic pain.

The application for benefits and a special award was dismissed.

The applicant's representative brought a motion to withdraw as counsel due to a complete breakdown in the solicitor-client relationship.

The applicant consented to the withdrawal.

The arbitrator granted the motion to withdraw, ordered the motion record sealed due to its sensitive and potentially prejudicial nature, and directed that a different arbitrator be selected to hear the case on the merits.

The applicant sought statutory accident benefits following a motor vehicle accident.

After a pre-hearing discussion where a settlement was reportedly reached, the applicant and his paralegal failed to execute the settlement documents and ceased communicating.

The insurer brought a motion to dismiss the application for arbitration.

The arbitrator dismissed the application as an abuse of process due to the applicant's failure to participate and ordered the applicant to pay the insurer's expenses of $1,983.15.

The appellant appealed an arbitrator's order precluding him from proceeding to arbitration for failure to attend insurer examinations (IEs) and finding his claim for attendant care benefits was time-barred.

The appellant was incarcerated at the time of the scheduled IE.

The Director's Delegate held that the arbitrator erred in refusing to consider the appellant's reasonable excuse for non-attendance.

The Delegate found that incarceration was a reasonable excuse, and the appellant had no duty to reschedule the IE upon his release; his only duty was to attend a properly scheduled IE.

The Delegate also found that the attendant care benefits claim was not time-barred, as it was for a limited period ending before the insurer's denial, and a formal denial is not a prerequisite for a dispute.

The appeal was allowed and the arbitrator's order was rescinded.

The applicant sought statutory accident benefits following a motor vehicle accident.

After her representatives were removed from the record due to a breakdown in the solicitor-client relationship, the applicant failed to attend the scheduled arbitration hearing despite receiving proper notice.

The arbitrator proceeded in her absence pursuant to Rule 37.9 of the Dispute Resolution Practice Code.

As the applicant bore the onus of proving entitlement and presented no evidence, the application was dismissed.

The insurer was awarded $1,000 in expenses for the preparation and attendance required.

The appellant appealed an arbitrator's decision denying his claim for an Income Replacement Benefit (IRB) following a motor vehicle accident.

The arbitrator had found that the appellant failed to produce requested financial documents regarding a corporation he controlled, making it impossible to calculate his income and resulting in an adverse inference.

On appeal, the Director's Delegate found no error of law in the arbitrator's credibility assessments, evidentiary rulings, or conclusion that the appellant failed to meet his burden of proof.

The appeal was dismissed.

The appellant was injured while riding a TTC bus that swerved to avoid a collision but did not strike any object.

She sought statutory accident benefits from the insurer of the other vehicle involved in the incident.

The Arbitrator held that section 268(1.1) of the Insurance Act acts as a complete bar to claiming statutory accident benefits from any source for occupants of a public transit vehicle involved in a non-collision incident.

On appeal, the Director's Delegate affirmed the decision, finding the statutory language clear and unambiguous.

The appellant, who was catastrophically impaired in a motor vehicle accident, claimed attendant care benefits for services provided by his daughter.

The daughter worked full-time at a youth facility.

The Arbitrator found that the services she provided in her employment were not similar enough to the convalescent care she provided to her father, and therefore the expenses were not 'incurred' under s. 3(7)(e)(iii)(A) of the SABS.

The Director's Delegate dismissed the appeal, holding that the Arbitrator's conclusion was a finding of fact not subject to review on appeal.

The applicant was injured in a rear-end motor vehicle accident and sought statutory accident benefits from the insurer.

The insurer denied several treatment plans, arguing the applicant's injuries fell within the Minor Injury Guideline (MIG).

The arbitrator found that the applicant's ongoing chronic pain and worsening psychological condition, which interfered with her functioning, removed her from the MIG.

The arbitrator approved treatment plans for physical therapy, psychological assessment and treatment, and chronic pain assessment, but denied several other assessments as premature or unnecessary.

The applicant was also awarded interest on overdue benefits.

The appellant appealed an Arbitrator's decision that he did not suffer a catastrophic impairment following a 2009 motor vehicle accident.

The central issue was whether the appellant suffered a marked impairment in the adaptation domain, largely based on his post-accident cannabis dependence and psychological issues.

The Director's Delegate upheld the Arbitrator's findings that the appellant's pre-accident cannabis use and behavioural issues were similar to his post-accident state, and that his impairment was only moderate.

The appeal was dismissed as the Arbitrator correctly applied the law and her factual findings were not subject to review on appeal.

The Applicant was injured in a motor vehicle accident and sought statutory accident benefits from the Insurer, including income replacement benefits, attendant care benefits, and payment for various medical treatments and assessments.

The Arbitrator found that the Applicant suffered from chronic pain and functional limitations, exacerbated by his functional illiteracy, which rendered him substantially unable to perform his pre-accident employment and completely unable to engage in any suitable employment post-104 weeks.

The income replacement benefit claim was granted.

The claim for attendant care benefits was dismissed, as the Applicant's family and friends did not suffer an economic loss, and the evidence did not support the need for 24/7 supervision.

Claims for medical treatments and assessments were partially granted based on reasonableness and necessity.