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Mount Sinai Hospital Benefits - Ontario Nurses' Association

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IN THE MATTER OF AN ARBITRATION<br />

PO( ftj<br />

BETWEEN:<br />

MOUNT SINAI HOSPITAL<br />

(The “<strong>Hospital</strong>”)<br />

and<br />

ONTARIO NURSES’ ASSOCIATION<br />

(The “Union”)<br />

Individual grievance of P.J. dated March 30, 2010<br />

SOLE ARBITRATOR: John Stout<br />

APPEARANCES:<br />

FOR THE HOSPITAL:<br />

Shane Smith, Counsel<br />

Barbara Griffin, Manager, Compensation and <strong>Benefits</strong><br />

Leslie Rodgers, Director of Human Resources<br />

FOR THE UNION:<br />

John D’Orsay, Labour Relations Officer<br />

Marie Haase, Labour Relations Officer<br />

Patti Lalla, Bargaining Unit President<br />

P. J., Grievor<br />

HEARING HELD IN TORONTO, ONTARIO, ON JULY 12, 2010<br />

1


AWARD<br />

I was appointed by the parties to hear and determine the individual<br />

grievance of P.J. (the “Grievor”) dated March 30, 2010 alleging failure of the<br />

<strong>Hospital</strong> to provide or continue to provide benefit coverage (the “Grievance”). The<br />

dispute centers on the provision of private nursing care services under the<br />

<strong>Hospital</strong>’s extended health and dental benefit plans. The issue to be determined<br />

in this award is whether the level of benefits under the <strong>Hospital</strong>’s extended health<br />

and dental benefit plans was decreased when the <strong>Hospital</strong> changed carriers in<br />

February 2010.<br />

The relevant provision of the Collective Agreement is article 17.03 which<br />

provides as follows:<br />

17.03 The <strong>Hospital</strong> may substitute another carrier for any of the foregoing<br />

plans (other than OHIP) provided that the level of benefits conferred<br />

thereby are not decreased. The <strong>Hospital</strong> will advise the Union of any<br />

change in carrier or underwriter at least sixty (60) days prior to<br />

implementing a change in carrier. The <strong>Hospital</strong> will provide the Union with<br />

a summary document outlining the differences, if any, between levels of<br />

benefits provided by the existing and new carrier plans. When the <strong>Hospital</strong><br />

is made aware, the <strong>Hospital</strong> will provide the Union with full details of any<br />

changes made by an existing carrier to current plan provisions.<br />

THE FACTUAL BACKGROUND<br />

The parties provided a number of agreed upon documents and an Agreed<br />

Statement of Facts. The <strong>Hospital</strong> also called two witnesses to testify.<br />

i. The Agreed Facts<br />

The Agreed Statement of Facts is set out below:<br />

2


The following facts, which set out the background regarding the change in<br />

carrier from Sun Life Financial to Great-West Life, are agreed to by the<br />

parties for the purposes of the hearing before Arbitrator John Stout in<br />

respect of the above referenced matter:<br />

1. <strong>Mount</strong> <strong>Sinai</strong> <strong>Hospital</strong> (the ‘<strong>Hospital</strong>’) issued a Request for Proposal<br />

in respect of, inter alia, extended health and dental benefits for its<br />

employees in August, 2009. A copy of this REP is Exhibit 3.<br />

2. At the time the REP was released, Sun Life Financial was the<br />

administrator of the <strong>Hospital</strong>’s extended health and dental benefit<br />

plans. The terms and conditions of the plan for members of the<br />

ONA bargaining unit were out in the Sun Life booklet which is<br />

Exhibit 10.<br />

set<br />

3. One of the listed selection criteria in the REP was that the<br />

successful bidder would replicate the existing plan design (meaning<br />

the plan design set out in Exhibit 10). the second page 1 in<br />

Exhibit 3.<br />

See<br />

4. There were a number of respondents to the REP. One of the<br />

respondents was Great-West Life (‘GWL’).<br />

5. GWL was ultimately selected by the <strong>Hospital</strong> the successful<br />

respondent to the REP. This was formally communicated to GWL<br />

in a letter dated October 22, 2009 which is Exhibit 12. Included in<br />

this letter is confirmation from the <strong>Hospital</strong> that the GWL plan is to<br />

duplicate the current plan design (meaning the Sun Life plan design<br />

as out in Exhibit 10).<br />

set<br />

6. GWL replaced Sun Life as the administrator of the <strong>Hospital</strong>’s<br />

extended health and dental benefits effective Eebruary 1, 2010.<br />

The terms and conditions of the plan administered by GWL are set<br />

out in the GWL booklet, which is Exhibit 11.<br />

7. DNA does not dispute that it was a condition of the RFP process<br />

established by the <strong>Hospital</strong> that any new plan would replicate the<br />

coverage out in Exhibit 10.<br />

set<br />

as<br />

ii. The Agreed Documents<br />

In addition to the Grievance (Ex. 1) and Collective Agreement (Ex. 9), the<br />

parties provided the following documents:<br />

3


1. Correspondence from Sun Life to P.J. dated April 14, 2008 with an<br />

attached Consultative Nursing Evaluation Report (Ex. 2).<br />

2. <strong>Mount</strong> <strong>Sinai</strong> <strong>Hospital</strong> Request for Proposal dated August 2009 (Ex.<br />

3)<br />

3. Memo from <strong>Mount</strong> <strong>Sinai</strong> <strong>Hospital</strong> Human Resources to Group<br />

benefit Plan members-DNA re: Carrier Change (Ex. 4)<br />

4. Documents relating to the reassessment process of Great-West<br />

Life (Ex. 5)<br />

5. Correspondence from Great West Life to P.J. dated March 8, 2010<br />

(Ex. 6)<br />

6. Correspondence from Geoff Maier, Senior Account Executive,<br />

Group <strong>Benefits</strong>, Great-West Life dated March 25, 2010 with<br />

attached adjudication notes (Ex. 7)<br />

7. Nursing Questionnaire completed by Dr. Samji dated May 23, 2009<br />

(Ex. 8)<br />

8. Sun Life Financial <strong>Mount</strong> <strong>Sinai</strong> <strong>Hospital</strong>, D.N.A. Extended Health<br />

and Dental Group Plan (Ex. 10) (the “Sun Life Plan”)<br />

9. Great-West Life <strong>Mount</strong> <strong>Sinai</strong> <strong>Hospital</strong>, O.N.A. Group Benefit Plan<br />

(Ex. 11) (the “Great-West Life Plan”)<br />

10. Correspondence from Barb Griffin, Manager Compensation &<br />

<strong>Benefits</strong> <strong>Mount</strong> <strong>Sinai</strong> <strong>Hospital</strong> to Geoff Maier dated October 22,<br />

2009 (Ex. 12)<br />

11. Email correspondence from Dr. Walker to Jennifer Hunter, Sun Life<br />

dated May 15, 2009 (Ex. 13)<br />

4


iii.<br />

Relevant undisputed facts found within the agreed upon documents<br />

The Grievor’s spouse suffers from ALS (Lou Gehrig’s Disease). The<br />

disease is well advanced and the Grievor’s spouse is on a ventilator. He requires<br />

health care services that would normally be provided in an Intensive Care Unit.<br />

The Grievor submitted a claim on behalf of her spouse for private nursing<br />

care services under the <strong>Hospital</strong>’s extended health and dental benefit plans. A<br />

Consultative Nursing Evaluation Report from Bayshore Home Health<br />

(“Bayshore”) was submitted in support of the claim.<br />

Sun Life Financial (“Sun Life”) was the carrier who administered the<br />

<strong>Hospital</strong>’s extended health and dental benefit plans at the time that the Grievor<br />

submitted her claim. On April 14, 2008 Sun Life wrote to the Grievor and based<br />

on the medical information received, approved the claim for the private nursing<br />

care services. Sun Life approved the services of an RN for 24 hours, 7 days a<br />

week. The e4ense incurred for the private nursing care services was<br />

reimbursed at 100%. In the letter approving the claim, the following was indicated<br />

regarding the coverage:<br />

“Your Group Health Plan does provide for the services of a<br />

Registered Nurse when the services are medically necessary and<br />

prescribed by a physician. As well, the duties being performed must<br />

require the expertise of a registered nurse.”<br />

In February 2010, Great-West Life replaced Sun Life as administrator of<br />

the <strong>Hospital</strong>’s extended health and dental benefit plans. The Grievor was<br />

required to submit documentation to Great-West Life to support her ongoing<br />

claim for private nursing care services. On February 19, 2010 the Grievor<br />

5


submitted a Nursing Care Health Assessment Form to Great-West Life in support<br />

of her claim.<br />

On March 8, 2010 Great-West Life denied the claim indicating as follows:<br />

Your plan with Great-West Life allows for nursing services for inhome<br />

nursing care provided by Registered Nurses or Registered<br />

Practical Nurses if it represents acute, convalescent or palliative<br />

care conditions only. Acute care is defined as the active<br />

intervention for the treatment of a short, sudden course of illness.<br />

Convalescent care includes rehabilitation for a condition that will<br />

return an individual to their previous level of health following illness<br />

or injury. Palliative care is the treatment of symptoms in the final<br />

stages of a terminal condition.<br />

According to the medical information provided, S.’s condition is<br />

chronic in nature. A chronic condition requires nursing or supportive<br />

care over a prolonged period for individuals who have lost or never<br />

acquired their full functional abilities. However, this type of nursing<br />

care is not a covered benefit of your plan. Therefore, any submitted<br />

or future nursing expenses will not be eligible for reimbursement by<br />

your plan.”<br />

On March 25, 2010, Geoff Maier, on behalf of Great-West Life, wrote to<br />

the Grievor indicating that while the claim was denied, it would be honored,<br />

outside the terms of the contract, for charges incurred from January 24 to March<br />

12, 2010.<br />

iv.<br />

The Benefit Plan Documents<br />

The relevant portions of the two benefit plans documents are as follows:<br />

a) The Sun Life Plan<br />

Extended Health Provision<br />

M-1<br />

Exclusions<br />

6


No Benefit is payable for<br />

• Expenses for which benefits are payable under a Workers’<br />

Compensation Act, Workplace Safety and Insurance Act or similar<br />

statute,<br />

• Expenses incurred due to intentionally self-inflicted injuries,<br />

• Expenses incurred due to civil disorder or war, whether or not war<br />

was declared,<br />

• Expenses for services and products, rendered or prescribed by a<br />

person who is ordinary a resident in the patient’s home or who is<br />

related to the patient by blood or marriage,<br />

• Expenses for which benefits are payable under a government plan,<br />

• Expenses for benefits which are legally prohibited by the<br />

government from coverage,<br />

• Out-of-province<br />

treatment or surgery.<br />

expenses<br />

for elective (non-emergency) medical<br />

M-2<br />

Extended<br />

Health —<br />

<strong>Hospital</strong><br />

Benefit<br />

Exclusions<br />

No benefit is payable for<br />

1. chronic or custodial care facilities,<br />

2.<br />

incurred under any of the conditions listed on the<br />

Extended Health Provision page as an Exclusion.<br />

expenses<br />

P-I<br />

Extended<br />

Health —<br />

Supplementary<br />

Health Care Benefit<br />

Q-1<br />

Eligible<br />

Expenses<br />

To be eligible, the<br />

treatment of<br />

otherwise specified.<br />

expenses<br />

disease<br />

must be medically necessary for the<br />

or injury and prescribed by a physician, unless<br />

Eligible<br />

of<br />

expense<br />

expenses<br />

are the reasonable and customary charges for the items<br />

listed below unless a maximum has been indicated.<br />

7


1. unlimited services of a registered nurse (R.N.) or registered<br />

practical nurse (R.P.N.) when provided in the patient’s home<br />

or in a hospital. To qualify as an eligible expense, the<br />

patient’s treatment must require the level of expertise of an<br />

R.N. or R.P.N. If an R.P.N. is only required but a R.N. rate<br />

was provided only the R.P.N. rate will be applied. All<br />

expenses for nursing services must be pre-approved by Sun<br />

Life.<br />

Q-2<br />

Exclusions<br />

No benefit is payable for<br />

1. expenses for the services of a homemaker, licensed practical nurse<br />

(L.P.N.) or certified nursing assistant (C.N.A.)<br />

2. expenses for items purchased solely for athletic use,<br />

3. dental expenses, except those specifically provided under Eligible<br />

Expenses for treatment of accidental injuries to natural teeth,<br />

4. utilization fees which are imposed by the provincial health care plan<br />

for the use of a service,<br />

5. expenses incurred under any of the conditions listed on the<br />

Extended Health Provision page as an Exclusion.<br />

b) The Great-West Life Plan<br />

Q-4<br />

Benefit Summary<br />

Healthcare<br />

Covered expenses will not exceed customary charges<br />

Basic Expense Maximums<br />

In-hospital and Home Nursing Care<br />

Unlimited<br />

IN-CANADA HOSPITAL<br />

Covered Expenses<br />

8


• Convalescent care for a condition that will significantly improve as a<br />

result of the care, provided it follows a 5-day confinement for acute<br />

care and begins within 14 days after you are discharged from<br />

hospital<br />

Limitations<br />

Except to the extent otherwise required by law, no benefits are paid for:<br />

• Chronic or custodial care<br />

H EALTHCARE<br />

Covered Expenses<br />

• In-hospital and home nursing services of a registered nurse (R.N.)<br />

or registered practical nurse (R.P.N.) who is not a member of your<br />

family, when services are provided in Canada, but only if the patient<br />

requires the specific skills of a trained nurse<br />

Limitations<br />

Except to the extent otherwise required by law, no benefits are paid for:<br />

• Chronic or custodial care<br />

v. Oral<br />

testimony<br />

Dale Fagan, a Senior Best Practice Medical Consultant with Sun Life<br />

testified with respect to the Sun Life Plan that was in place prior to February 2010<br />

and the Grievor’s claim.<br />

Ms. Fagan testified that<br />

she<br />

had reviewed and was familiar with the Sun<br />

Life Plan. She indicated that some of the wording and particularly the wording<br />

regarding private nursing care services was not “Sun Life standard wording”.<br />

According to Ms. Fagan unlimited coverage is unusual and not standard. The<br />

standard coverage for Sun Life is a $25,000 maximum per 3 calendar years. In<br />

9


this case, the claim was approximately $10,800.00 per week for private nursing<br />

care services.<br />

During her testimony, Ms. Fagan reviewed the exclusions under the Sun<br />

Life Plan. According to Ms. Fagan, the exclusion found in the Extended Health -<br />

Supplementary Health Care Benefit section of the Sun Life Plan at page Q-4 is in<br />

reference to the general exclusions found on the Extended Health Provision at<br />

page M-2. This exclusion provides as follows:<br />

5. expenses incurred under any of the conditions listed on the Extended<br />

Health Provision page as an Exclusion.<br />

Ms. Fagan also indicated that the exclusions under the Extended Health —<br />

<strong>Hospital</strong> Benefit section of the Sun Life Plan at page P-I did not apply to the<br />

private nursing care services benefits found in the Extended Health-<br />

Supplementary Health Care Benefit section of the Sun Life Plan at page Q-2.<br />

Specifically, Ms. Fagan indicated that the following exclusion did not apply to the<br />

private nursing care services benefit:<br />

I. chronic or custodial care facilities<br />

In terms of the process for adjudicating the claim for private nursing care<br />

services, Ms. Fagan indicated that a plan member would be directed to Bayshore<br />

to perform an assessment. A claimant would provide all the relevant information<br />

to Bayshore. Bayshore would then provide the claims officer with an assessment.<br />

The claims officer then reviews the assessment to decide whether to approve the<br />

claim. During this process, the claims officer may or may not consult with a<br />

physician.<br />

Ms. Fagan indicated that whether the condition of a patient is palliative or<br />

acute is not relevant to assessing the claim for private nursing care services<br />

10


under the Sun Life Plan. According to Ms. Fagan the duties of the nurse and<br />

what they perform are the relevant factors. She went on to state that it was of no<br />

significance whether the care being provided was chronic or convalescent unless<br />

such care was being provided in a chronic care facility or the chronic wing of a<br />

hospital.<br />

Ms. Fagan indicated that she would have approved the Grievor’s claim<br />

solely on the basis of the Bayshore assessment. Ms. Fagan also identified an<br />

email dated May 15, 2009 from Dr. Walker who indicated as follows:<br />

“I agree this looks like a reasonable situation to continue the nursing up to<br />

24 hr per day, 7 days per week to wrap around the 40 hours per week<br />

provided by CCAC in <strong>Ontario</strong>. 62 year old man with ALS is on a ventilator<br />

for over a year. G-tube fed, unable to verbally communicate due to<br />

tracheotomy and is DNR. The ventilator is obviously keeping him alive and<br />

with good nursing care he will live for awhile yet. I don’t see how we can<br />

reduce it. I suppose you could ask for a confirmation that his status is<br />

unchanged. I would not ask for a formal nursing consultation.”<br />

Kim Gerrie, Director of Group <strong>Benefits</strong> with Great-West Life also testified.<br />

Mr. Gerrie testified that the Great-West Plan was an administrative services only<br />

(ASO) contract with a stop loss arrangement. As a result, the <strong>Hospital</strong> is<br />

responsible for payment of any individual claim up to $20,000.00. Any individual<br />

claim over $20,000.00 is insured. Mr. Gerrie advised that private nursing care<br />

services were generally a benefit that assists persons recovering in a<br />

convalescence situation and in some cases a palliative situation. Mr. Gerrie<br />

indicated that the wording in the Great-West Life Plan was the normal usual<br />

wording for private nursing care services, although he conceded that unlimited<br />

coverage is rare. He went on to indicate that it would be highly unusual to have<br />

unlimited private nursing care services without any exclusion.<br />

11


Mr. Gerrie testified about the Grievor’s claim with Great-West Life.<br />

According to Mr. Gerrie, the claim was denied based on the Grievor’s spouse’s<br />

condition being chronic. Mr. Gerrie referenced the limitation found at page 20 of<br />

the Great-West Plan relating to “chronic or custodial care”. Mr. Gerrie explained<br />

that this is a very common limitation and the rationale supporting the limitation is<br />

that the benefit is intended to supplement and not replace provincial healthcare.<br />

Mr. Gerrie also explained that there could be other limitations in the Great-West<br />

Plan. However, the adjudication process does not continue after an initial<br />

limitation factor has been identified.<br />

Mr. Gerrie identified what he described as a “similar but not the same<br />

limitation” in the Sun Life Plan. Mr. Gerrie referenced the “Exclusions” found on<br />

page P-i of the Extended Health -<br />

<strong>Hospital</strong><br />

Benefit. Mr. Gerrie indicated that it<br />

was expected that the normal limitations found in the Great-West Life Plan would<br />

also be found in the Sun Life Plan. Mr. Gerrie pointed to the “Exclusions under<br />

the Sun Life Plan’s Extended Health -<br />

<strong>Hospital</strong><br />

Benefit at page P-I (“chronic and<br />

custodial care facilities”) as being incorporated as an exclusion applying to the<br />

private nursing care services benefit found in the Extended Health -<br />

Supplementary Health Care benefit at page Q-4. Specifically, he pointed to the<br />

following language as incorporating any other exclusion in the Extended Health<br />

benefits component:<br />

5. expenses incurred under any of the conditions listed on the Extended<br />

Health Provision page as an Exclusion.<br />

During cross-examination Mr. Gerrie agreed that he reviewed the Request<br />

for Proposal (REP) that was provided by the <strong>Hospital</strong>. The REP provided a<br />

general outline of the Sun Life Plan and included claims experience data. It was<br />

pointed out to Mr. Gerrie that the claims experience data for private nursing care<br />

services applicable to DNA members went from 0 in 2007, to $141,000 in 2008<br />

and $265,894 in 2009. Mr. Gerrie acknowledged the numbers but also indicated<br />

that his earlier review was in relation to the aggregate numbers found in the RFP<br />

and not any specific claim experience. Mr. Gerrie also indicated that he did not<br />

12


acquire a copy of the Sun Life Plan until a couple months before the effective<br />

date for the Great-West Life Plan.<br />

POSITION OF THE UNION<br />

The Union submitted that the <strong>Hospital</strong> decreased the level of benefits<br />

when it changed carriers from Sun Life to Great-West Life. The Union accepts<br />

that the <strong>Hospital</strong> did not intend to decrease benefits. However, the Union argued<br />

that is what has occurred in this situation. In particular, the Union suggested that<br />

under the Sun Life Plan, the private nursing care services benefit did not include<br />

any exclusion for chronic conditions. The Union pointed to the evidence of Ms.<br />

Fagan as supporting their position. The Union argued that the interpretation of<br />

Mr. Gerrie should be rejected as it is inconsistent with the interpretation of Sun<br />

Life and the language found in the Sun Life Plan.<br />

POSITION OF THE HOSPITAL<br />

The <strong>Hospital</strong> submitted that the benefit for private nursing care services<br />

was not decreased when they changed carriers. The <strong>Hospital</strong> argued that both<br />

plans have a limitation for chronic care. The <strong>Hospital</strong> suggested that the<br />

exclusions found in the Extended Health Provision at page M-2 of the Sun Life<br />

Plan and any other applicable exclusion is incorporated into all the other<br />

extended healthcare benefits, including private nursing care services under the<br />

Extended Health - Supplementary Health Care Benefit. As a result the exclusion<br />

of chronic or custodial care facilities under the Extended Health —<br />

<strong>Hospital</strong><br />

Benefit at page P-I is applicable to the private nursing care services benefit in<br />

the Extended Health —<br />

Supplementary Health Care Benefit at page Q-2. It was<br />

suggested that this interpretation is consistent with the principle of extended<br />

health benefits supplementing government health services. The <strong>Hospital</strong><br />

suggested that the Union’s interpretation of the Sun Life Plan would be replacing<br />

government medicare in a cost prohibitive manner. The <strong>Hospital</strong> suggested that<br />

the evidence of Ms. Fagan was unreliable and not credible.<br />

13


DECISION<br />

After carefully considering the evidence and submissions of the parties I<br />

conclude, based on the particular facts of this case, the Grievance must be<br />

allowed.<br />

The issue to be decided is whether the level of benefits was decreased<br />

when Great-West Life was substituted for Sun Life as the carrier for the<br />

<strong>Hospital</strong>’s extended health and dental benefit plans. The determination of this<br />

issue is dictated by comparing the level of benefits provided under each<br />

respective carrier’s plan. More specifically, the issue focuses on comparing the<br />

level of benefits for private nursing care services provided under each carrier’s<br />

plan.<br />

The clear language of the Sun Life Plan supports the Union’s position. The<br />

Extended Health Provision includes a number of general exclusions. These<br />

general exclusions are incorporated into the exclusions for specific benefits by<br />

including the following language<br />

“expenses incurred under any of the conditions listed on the Extended<br />

Health Provision page as an Exclusion.”<br />

See for example the exclusions found within the specific benefits at pages N-2,<br />

0-1, P-i, Q-4, and QI-5.<br />

The specific exclusion for chronic or custodial care facilities under the<br />

Extended Health - <strong>Hospital</strong> Benefit found at page P-I has not been incorporated<br />

as an exclusion that would apply to the private nursing care services benefit<br />

under the Extended Health - Supplementary Health Care Benefit at page Q-2.<br />

Ms. Fagan’s testimony regarding the application of the language under the<br />

Sun Life Plan is consistent with my interpretation that the private nursing care<br />

14


enefit under the Sun Life Plan’s Extended Health - Supplementary Health Care<br />

Benefit did not include any exclusion for chronic conditions.<br />

The Great-West Life Plan clearly includes a limitation for chronic or<br />

custodial care with respect to the private nursing care services benefit under their<br />

plan. As indicated above, this limitation is not found under the Sun Life Plan.<br />

Accordingly, the level of this benefit has been decreased when the carriers were<br />

substituted.<br />

I accept that providing unlimited private nursing care is not usual or<br />

ordinary. I also acknowledge that the cost associated with this benefit is<br />

extraordinary in the circumstances of this case. [-lowever, the clear language of<br />

the Sun Life Plan and the manner in which it was applied indicates that this was<br />

the level of benefit enjoyed prior to the carrier being changed to Great-West Life.<br />

Finally, I was provided with no evidence or authority that would suggest<br />

that providing unlimited private nursing care services under an insurance plan<br />

without a limitation for chronic care was prohibited under the government<br />

medicare program (OHIP).<br />

For all the reasons stated above, I<br />

make the following determinations:<br />

• The level of the private nursing care benefit was decreased when the<br />

carriers were substituted.<br />

• I direct the <strong>Hospital</strong> to address the deficiency in the level of benefits for<br />

private nursing care services provided under the Great-West Life Plan.<br />

• I remit the matter of remedy and damages to the parties.<br />

15


In accordance with the parties’ request, I remain seized in the event there<br />

is a dispute concerning the interpretation, application and implementation of this<br />

award, and I remain seized of any remedy and claim for damages.<br />

Dated at Toronto, <strong>Ontario</strong> this 1gth day of July 2010.<br />

4 —<br />

i/ri<br />

John Stout - Arbitrator<br />

16

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