Category: Income Replacement Benefits

Aized v. The Co-operators (20-012300)

The claimant applied to the LAT for post-104 week IRBs and medical benefits, including physiotherapy services and an attendant care assessment. Prior to the accident, the claimant was employed as a student placement coordinator, which required concentration, critical thinking skills and sitting in front of a computer screen for prolonged periods of time. Despite returning to work with reduced hours and the ability to work remotely, the claimant argued that she was unable to perform the essential responsibilities of her job and that working full-time exacerbated her pain. The insurer argued that the claimant was substantially able to perform the tasks of her pre-accident employment with modified duties and, therefore, she did not suffer from a complete inability to engage in any employment for which she was reasonably suited. Having regard to the deterioration in the claimant’s psychological condition and the pain caused by the accident, Vice-Chair Logan found that, although the claimant was substantially unable to perform the essential tasks of her pre-accident employment, she was still capable of engaging in alternative employment for which she was reasonably suited. Vice-Chair Logan held that a claimant’s ability to perform “some, albeit not all” of the responsibilities of their pre-accident employment strongly indicates that they are able to continue to engage in their pre-accident employment and in alternate forms of employment that they may be reasonably equipped for. As a result, the claimant was only entitled to pre-104 week IRBs. Vice-Chair Logan concluded that the claimant had no objective quantifiable physical impairments from the accident and refrained from seeking out physiotherapy earlier upon being advised by her physician. In addition, Vice-Chair Logan held that an attendant care assessment was not reasonable or necessary given that the claimant did not suffer from any residual physical impairments and could not draw upon her treatment plan as evidence that attests to the need for an attendant care assessment. As a result, the claimant was not entitled to medical benefits.

Nouracham v. Aviva General Insurance Company (21-000224)

The claimant applied to the LAT for entitlement to IRBs. Prior to the accident, the claimant, who worked as an employee on an “on call” basis, had not been called upon to work for a period of six weeks. The insurer denied IRBs on the basis that the claimant was not eligible for IRBs because she was not earning wages for herself at the time of the accident. Adjudicator Evans concluded that the existence of an employee relationship alone does not satisfy the employment criteria under s. 5(1)(1)(i) of the SABS. Rather, the employment criteria of s. 5(1)(1)(i) will be satisfied when an employment relationship is ongoing and a given accident occurs during a time when the claimant is receiving remuneration for services. As a result, the claimant was not entitled to an IRB and the application was dismissed.

Kokulanthan v. TD General Insurance Company (20-011886)

The insurer raised a preliminary issue, arguing that the claimant’s entitlement to medical benefits and IRBs was barred for non-attendance at s. 44 examinations. Adjudicator Tavlin Kaur found that the insurer’s notices of examination in relation to IRBs did not comply with the SABS as they did not refer at all to the claimant’s medical conditions or the SABS provisions on which the insurer relied. The claimant was permitted to continue to a hearing for her IRB claim. Adjudicator Kaur found that the insurer’s notice with respect to medical benefits was satisfactory as it referenced the MIG, medical and rehabilitation benefits, and the claimant’s medical condition. The claimant’s claims relating to medical and rehabilitation benefits were barred from proceeding to a hearing. Adjudicator Kaur declined to exercise her discretion to allow the claimant to continue with these issues as she had not provided reasons for her non-attendance at the insurer examinations, nor had she made any written submissions at the preliminary issue hearing.

Waterloo Insurance v. Switzer (2023 ONSC 604)

The insurer appealed the Tribunal’s decision regarding the calculation of a self-employed person’s IRB where the person was self-employed for less than one year. The Tribunal allowed the claimant to use income earned from his previous employer, despite not being employed at the time of the accident and not being employed in the six months prior to the accident. The Court overturned the Tribunal’s decision, holding that the claimant was not permitted to use income earned through employment in calculating IRBs because he did not qualify for IRBs as an employed person. As a self-employed person at the time of the accident, the calculation of IRBs was limited to the calculation based on the last completed taxation year, as required by section 4(3). Due to the lack of evidence regarding the property calculation, the Court ordered a new hearing before the Tribunal, applying the proper section of the SABS.

Balasubramaniam v. Aviva General Insurance Company (21-001010/AABS)

The LAT found that the claimant was not entitled to a repayment of IRBs due to non-compliance with s. 33 of the Schedule. The claim was initially heard before Arbitrator Kowalski at the Financial Services Commission of Ontario where it was ordered that the insurer pay a weekly IRB. After the arbitration, the insurer was advised that the claimant had been earning income which could reduce the quantum of the IRB to nil. Adjudicator Grant agreed that the insurer could not rely on s. 287 of the Insurance Act to suspend or modify the Order for IRB payments but found that the insurer could suspend IRBs due to the claimant’s non-compliance with s. 33.

Schuknecht v. Economical Insurance Company (19-013098)

The insurer’s request for reconsideration was granted. The issue at the hearing was the correct calculation of the quantum of IRBs. The hearing adjudicator had found the claimant was entitled to IRBs in the amount of $172.00 per week after the claimant reached age 65. The insurer argued that the LAT made errors with respect to entitlement of IRBs and in awarding a post-65 IRB. In the Reconsideration Decision, Vice-Chair Maedel agreed that current entitlement to IRBs was not in dispute and only the quantum of IRBs was at issue. Therefore, reference to ‘entitlement’ or ‘up to age 65’ was removed from the original decision. In addition, Vice-Chair Maedel agreed with the insurer that the LAT violated rules of natural justice or procedural fairness when ordering entitlement to IRBs after age 65 because the claimant was 57 years of age at the time the decision was made. Vice-Chair Maedel found that imposing an IRB 8 years into the future was to speculate about the claimant’s condition, entitlement, and the status of the applicable law in the future. Vice-Chair Maedel stated that while the claimant’s entitlement to IRBs was ‘ongoing’, the term “ongoing” does not equate to “forever”. That being said, Vice-Chair Maedel noted the claimant was protected by terms of s. 281(2) of the Insurance Act, which states that following a Tribunal Decision, the insurer may reduce benefits only if the applicant agrees, the insurer is authorized to do so as a result of successful appeal of the Tribunal Decision, or the insurer is authorized to do so by the Tribunal.

Lacroix v. Intact Insurance Company (20-12380/AABS)

The claimant applied to the LAT seeking entitlement to IRBs. The insurer denied IRBs, noting that prior to the accident the claimant was working on a part-time basis and that she had managed to secure a position as a waitress after the accident. The claimant attempted to establish that her medical records showed that she sustained WAD II, tennis elbow, and disc bulges as a result of the accident, which prevented her from working. Adjudicator Kepman accepted these reports but found that they did not draw a meaningful nexus between the claimant’s injuries and the accident. Adjudicator Kepman found the insurer’s position to be more credible and determined that the claimant was not entitled to payment of IRBs.

Jeffery v. Travelers Insurance Company of Canada (20-013979/AABS)

The claimant was denied IRBs and medical benefits and sought entitlements to the benefits along with a Special Award from the Tribunal. The Tribunal held that the claimant was not entitled to IRBs or medical benefits for physiotherapy treatment. The adjudicator held that since no benefits were owed to the claimant, a s. 10 award was not applicable. The adjudicator found that the insurer did not comply with s. 36(4), which required that the insurer shall pay the benefit or give notice with medical reasons and any other reasons why it will not pay the benefit within 10 days of receiving an application and completed disability certificate. The insurer did provide notice to the claimant but did not provide medical reasons for refusing the application and relied on the fact that the claimant returned to work within 7 days of the accident. In addition, the insurer’s notice was not considered proper as it did not include the right to appeal the decision. Eventually, the insurer provided the proper notice with the appropriate medical reasons. The statutory entitlement for breaching s. 36(4) was determined to be for the period where the claimant was not given the proper notice. However, since the claimant was working during the period of statutory entitlement, the claimant’s actual entitlement was nil.

Ding v. Wawanesa Insurance (20-008236/AABS)

The LAT was asked to determine whether the claimant was entitled to IRBs in the amount of $400 per week. The claimant relied on the submission of medical evidence to demonstrate that he suffered a substantial inability to perform the essential tasks of his self-employment as a result of the accident. The claimant also argued that the disclosure requests of the insurer had been excessive. The insurer agreed that the claimant was entitled to IRBs but disagreed as to quantum. Adjudicator Kepman found for the insurer, noting that it had made repeated efforts to determine whether the claimant was self-employed and to quantify his earnings. Though the claimant eventfully provided most of the requested documents, upon receipt inconsistencies became clear. Adjudicator Kepman highlighted that when considering the quantum of entitlement to IRBs for a self-employed person, the insurer must be able to clearly analyse the impact of the accident on income. The LAT concluded that the claimant failed to provide sufficiently detailed information. As he had failed to provide the required disclosure, he had also failed to prove entitlement to an IRB quantum of $400 per week.

Chen v. The Co-operators (20-012408/AABS)

The claimant applied to the LAT seeking entitlement to various benefits, including the ongoing payment of IRBs. The insurer denied IRBs on the basis that the claimant had provided insufficient medical evidence to prove that she suffered a substantial inability to perform the essential tasks of her employment as a manicurist. The claimant’s productions lacked clinical notes and records. Instead, the claimant relied on annotations provided in the OCF-18s and an OCF-3. Vice-Chair Todd found for the insurer, concluding that while the notations were helpful to the Tribunal, they did not replace the need for more thorough medical assessments. Further, the OCF-3 contained a list of the claimant’s injuries and sequelae with no explanation as to why these injuries prevented her from performing her job duties. Vice-Chair Todd also noted that the submitted OCF-2 was incomplete and therefore less credible. The claimant was found to not be entitled to IRBs.