Ontario Financial Services Commission - Dispute Resolution Services

The Applicant was catastrophically injured in a motor vehicle accident and previously awarded statutory accident benefits, including income replacement, attendant care, and nutritional counselling.

In this resumed hearing, the Arbitrator determined the Applicant's entitlement to interest on overdue benefits and a special award.

The Arbitrator found the Insurer liable for interest on all three benefit categories, noting the Insurer had sufficient information to adjust the claims early on despite procedural delays by the Applicant.

Furthermore, the Arbitrator ordered a special award of $750,000 against the Insurer under section 282(10) of the Insurance Act, finding the Insurer's conduct in handling the attendant care and nutritional counselling claims to be significantly blameworthy and in breach of its statutory obligations.

The applicant, a wheelchair user, was injured when a bus stopped suddenly.

The insurer terminated attendant care and housekeeping benefits after 104 weeks, finding she did not suffer a catastrophic impairment.

The applicant brought a motion for interim benefits pending arbitration.

The arbitrator found the applicant established a prima facie case that she suffered a total and permanent loss of use of her left arm, meeting the catastrophic impairment definition.

The arbitrator also found urgency and hardship, as the applicant required additional attendant care following her husband's death to avoid moving to a long-term care facility.

Interim attendant care benefits of $1,117.25 per month were awarded, but interim housekeeping benefits were denied.

The applicant was injured in a motor vehicle accident and claimed attendant care benefits for services provided by his spouse, a stay-at-home parent.

The insurer denied the claim because the spouse did not sustain an economic loss.

The arbitrator held that under the 2010 Statutory Accident Benefits Schedule, a family member providing care must either sustain an economic loss or provide the services in the course of their employment, occupation, or profession.

A stay-at-home parent does not meet the definition of providing care in the course of an occupation.

The application for attendant care benefits was dismissed.

The insurer sought repayment of statutory accident benefits paid to four applicants, alleging the motor vehicle accident was staged.

The applicants failed to attend the hearing.

Relying on uncontroverted accident reconstruction evidence, the arbitrator found the accident did not occur as reported and that the applicants received benefits as a result of wilful misrepresentation.

However, interpreting section 47(1)(a) of the Schedule strictly, the arbitrator held the insurer could only recover benefits paid directly to the insured persons, not those paid to third-party service providers.

Three applicants were ordered to repay the amounts paid directly to them, and all four were ordered to pay the insurer's arbitration expenses.

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

The insurer disputed that an accident took place.

The applicant's representative withdrew after losing contact with her for over three years.

The applicant failed to attend the preliminary issue hearing despite being served with notice.

As the applicant did not present any evidence to establish that an accident occurred, her claims for accident benefits were dismissed.

The applicant was injured in a motor vehicle accident and claimed attendant care benefits under a transitional policy.

The insurer brought a motion to determine whether the applicant was required to prove economic loss under subsection 3(7)(e) of the 2010 Schedule.

The applicant argued that his rights under the 1996 Schedule had vested at the commencement of the policy period.

The Arbitrator held that the right to benefits is contingent upon involvement in a motor vehicle accident and only vested on the date of the accident, which occurred after the 2010 Schedule came into force.

Therefore, proof of economic loss is required.

The applicant died of causes unrelated to a motor vehicle accident while his claim for accident benefits was pending.

The arbitration process was paused to allow for the appointment of an estate trustee.

After more than two years, the applicant's family confirmed they had no plans to appoint a representative.

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

The arbitrator found the claims could not be pursued without a legally appointed representative and dismissed the application on consent, with no order as to expenses.

The parties settled the applicant's claim for statutory accident benefits prior to the arbitration hearing, leaving only the issue of expenses to be determined.

The applicant sought $25,228.49 in fees and disbursements.

The arbitrator found that the applicant was entitled to expenses, but reduced the claimed amounts, noting that the matter was not complex and that certain disbursements for web-based document services were not recoverable.

The arbitrator fixed the applicant's expenses at $12,250.00, inclusive of fees, disbursements, and taxes.

Following the dismissal of the applicants' claims for non-earner benefits, the insurer sought its expenses of the arbitration.

The arbitrator found the insurer was entitled to its expenses based on its complete success, despite some conduct that prolonged the hearing.

The insurer voluntarily reduced its claim to $5,000 inclusive of taxes and disbursements.

After disallowing a non-recoverable disbursement for reporting services, the arbitrator ordered each applicant to pay the insurer $2,029.92 in expenses.

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

The insurer denied two treatment plans and argued that the applicant was precluded from proceeding to arbitration because he failed to commence proceedings within the two-year limitation period under section 56 of the Statutory Accident Benefits Schedule and section 281.1 of the Insurance Act.

The arbitrator found that the applicant had filed for mediation within two years of the insurer's refusals and subsequently filed for arbitration within 90 days of the mediator's reports.

Therefore, the limitation periods had not expired, and the applicant was permitted to proceed to arbitration on both treatment plans.

The Respondent brought a motion during a preliminary appeal conference to compel the Appellant to order and pay for the transcript of his own testimony from the arbitration hearing.

The Appellant argued he could not afford the transcripts and did not intend to rely on them.

The Director's Delegate dismissed the motion, finding that the onus is on the moving party to establish that further portions of the transcript should be ordered, and that there is nothing preventing the Respondent from ordering the transcripts itself if it believes they are necessary for a full and fair appeal hearing.

The applicant was injured in a motor vehicle accident and sought statutory accident benefits, including income replacement, attendant care, and housekeeping benefits.

The insurer terminated these benefits based on independent medical assessments.

The arbitrator found that the applicant suffered a substantial inability to perform the essential tasks of his pre-accident employment as a chef and awarded income replacement benefits, subject to deduction for post-accident employment income.

However, the claims for attendant care and housekeeping benefits were dismissed, as the applicant failed to establish that he required the extent of assistance claimed.

The applicant sought accident benefits following a motor vehicle accident.

After a settlement was reportedly reached at a pre-hearing discussion, the applicant failed to execute the settlement documents and ceased communicating with her counsel.

At the scheduled arbitration hearing, the applicant did not appear.

Her counsel was granted permission to withdraw from the record.

As no evidence was introduced to support the applicant's claims, the application was dismissed.

The applicant was ordered to pay $500 in expenses to the insurer for unduly prolonging the proceeding.

The insurer brought a motion to dismiss the applicant's claims for statutory accident benefits.

The applicant, who resided in the U.K. and was self-represented, failed to comply with production requests over a seven-month period and indicated she had no plans to attend the scheduled arbitration hearing in Toronto.

The arbitrator found that the applicant was not taking the arbitration process seriously and that the proceeding had become vexatious.

The application for arbitration was dismissed pursuant to Rule 68 of the Dispute Resolution Practice Code, with no order as to expenses.

The applicant applied for arbitration regarding statutory accident benefits following a motor vehicle accident.

After participating in early stages of the proceeding, the applicant failed to attend the resumed pre-hearing and the scheduled arbitration hearing.

The insurer requested an order dismissing the application.

The arbitrator dismissed the application for arbitration due to the applicant's failure to participate.

The applicant was injured when she fell inside a public transit bus due to sudden acceleration.

She applied for statutory accident benefits, claiming housekeeping and home maintenance benefits as well as the cost of custom orthotics, which the insurer denied.

The arbitrator found the applicant's testimony regarding her symptoms credible and supported by objective medical evidence, including an MRI showing a tear in her right wrist and an ankle effusion.

The arbitrator rejected the insurer's medical assessments, noting they failed to consider the MRI results.

The applicant was awarded housekeeping benefits at $100 per week for the initial period and $50 per week thereafter, along with the cost of the custom orthotics and interest on overdue payments.

The appellant appealed an arbitrator's decision denying her claims for caregiver and non-earner benefits following a motor vehicle accident.

The Director's Delegate found no error of law in the arbitrator's weighing of the medical evidence, which preferred the insurer's assessments over the appellant's experts.

The Director's Delegate also rejected the argument that the arbitrator erred by allowing the appellant to proceed unrepresented, noting there was a presumption of capacity and no signs of mental difficulty that would require an inquiry under the Substitute Decisions Act.

The appeal was dismissed.

The applicant was struck on the head by a parking garage control arm while walking into the garage behind a car.

He applied for statutory accident benefits, but the insurer denied the claim, arguing the incident was not an 'accident' under section 2(1) of the Schedule.

The arbitrator found that the car entering the garage triggered the arm to lift and lower, satisfying both the purpose and causation tests.

The arbitrator concluded that the use or operation of the car directly caused the injury, and therefore the applicant was injured in an 'accident'.