R.A. v. Intact Insurance Company (16-003508)

The claimant sought entitlement to attendant care benefits. The insurer asserted a limitations defense. Adjudicator Therese Reilly reviewed the denial letter relied upon by the insurer and determined that the letter was not clear and unequivocal to trigger the limitations clock. The letter of the insurer was a notice of examination which did not properly provide sufficient notice, and the subsequent denial was, in fact, a suspension of benefits, not a denial. As a result, the claimant was permitted to pursue a claim for attendant care benefits.