Category: Late Application

P.M. v. RBC General Insurance Company (16-001611)

The claimant suffered a finger fracture in the accident. He was new to Canada and did not understand the accident benefits system. He first applied for EI, which was denied; he appealed and lost again. He first applied for accident benefits eight months after the date of loss. The insurer argued that the claimant did not have a reasonable explanation for his delay and could not claim accident benefits. Adjudicator Gottfried followed FSCO case law regarding late applications and concluded that the claimant did have a reasonable explanation for his late application, and that he could claim accident benefits. He was found entitled to IRBs based on his injuries from the date of his first OCF-3 up to the 104 week mark. IRBs beyond that date were denied. Various medical benefits were paid by the insurer. Adjudicator Gottfried held that claims for HST on proposed medical benefits were also payable.

N.F. v. Aviva Insurance Company of Canada (17-000456)

The claimant sought entitlement to a number of medical benefits. In addition to a MIG position, the insurer asserted that the claimant was barred from bringing a claim as notice to claim accident benefits was not provided within seven days (or reasonably thereafter) of the MVA, pursuant to sections 32 and 55. Adjudicator S.F. Mather reviewed the circumstances leading up to the claimant providing an application for accident benefits three months following the MVA and determined that the time it took to bring the claim was not unreasonable. Although the application was incomplete, Adjudicator Mather ruled it was reasonable to obtain the missing information on review of the overall claim. With respect to the medical benefits claimed, Adjudicator Mather ruled that the notice letters did not take a position on the MIG and did not provide medical reasons for the denial. As a result, the insurer was precluded from taking a MIG position, and therefore must pay for the treatment plans claimed. No discussion of whether the treatment was reasonable was needed, since the provisions make it clear an insurer shall pay for treatment it fails to provide notice to, until the notice is cured. Therefore the treatment plans claimed were deemed payable.