Nguyen v. Economical Mutual Insurance Company (2023 ONSC 2541)

The claimant appealed the LAT’s decision that the limitation period barred the application. The Court allowed the appeal and remitted the matter to the Tribunal for a new hearing. The Court found the Tribunal erred in concluding that the denial letter was received on the day it was authored, as no evidence was before the Tribunal to prove the date of receipt. The Court also held the Tribunal erred in putting the onus on the claimant to refute the date the insurer alleged the denial letter was received by the claimant in the mail.

Varriano v. Allstate Insurance Company of Canada (2023 ONCA 78)

The insurer appealed the Divisional Court’s decision that the limitation period on IRBs did not commence because the denial did not provide any medical reasons. The insurer argued that the only basis for denial was the claimant’s return to work (i.e. an “other” reason), and that it was not required to state a medical reason where one did not exist. The Court of Appeal agreed, reversing the Divisional Court’s decision. The Court held that the phrase “medical and any other reason” used the word “and” in a joint and several sense. The Court recognized that some cases will have both medical reasons and other reasons; some cases will have only medical reasons or only other reasons. The insurer was not required to invent a medical reason for the denial where one did not exist. The denial of further IRBs based on the return to work complied with section 37, and was sufficiently clear and unequivocal to trigger the limitation period.

Fu v. Pembridge Insurance Company (21-012902)

The claimant applied to the LAT seeking entitlement to NEBs and medical benefits. The insurer argued that the claimant was barred from seeking entitlement to the benefits because he did not dispute the denials within the two-year limitation period. The accident occurred in December 2018, the insurer denied entitlement to NEBs and medical benefits between January and March 2019, and the LAT application was filed in October 2021. The claimant was a minor at the time of the accident. He argued that entitlement to NEBs should be considered discovered when he became eligible on his 18th birthday (September 2020) and, accordingly, the LAT application was within the two-year limitation period. He requested an extension of time with regards to the medical benefits. Adjudicator Kaur held that nothing in s. 36 of the SABS sets out a separate process for applying for NEBs for minors and that nothing in s. 36 makes it a requirement to be 18 to apply for NEBs. Adjudicator Kaur found that the claimant met the eligibility requirement to apply for NEBs under s. 12(1)2i of the SABS at the age of 16 when he was a full-time student (even though an insurer is not required to pay NEBs before an insured is 18 years old). Adjudicator Kaur was not persuaded by the discoverability argument and found that the claimant applied to LAT after the two-year limitation period had expired. Adjudicator Kaur declined to extend the limitation period pursuant to s. 7 of the LAT Act. The application was dismissed.

Traders General Insurance Company v. Rumball (2022 ONSC 7215)

Both the insurer and the claimant appealed the Tribunal’s decision that the claimant was entitled to IRBs up to the 104 week mark. The insurer appealed the finding that the limitation period did not bar the IRB claim because the denial was not clear and unequivocal. The claimant appealed the finding that she was not entitled to post-104 week IRBs. The Court dismissed both appeals. Regarding the limitation period, the Court noted that the matter was one of mixed fact and law. The Tribunal’s finding that the denial was not clear and unequivocal was not open to appeal as it was not an error of law. Regarding the post-104 week IRBs claim, the Court held that the only applicable disability test is the “complete inability” test in the SABS. The Court rejected the claimant’s argument that the standard described in Burtch v. Aviva (a test stating that suitable employment means employment in a competitive, real-world setting, considering an employer’s demands for reasonable hours and productivity and a test that the work should also be comparable in terms of status and wages), as it was not stated in the SABS. The Tribunal held that the claimant had reasonably suitable alternative employment available to her, and that she had some functional ability to work in the retail sector. As such, there were no reviewable legal errors for the Court to address.

K.D. v. Certas Direct Insurance Company, (19-003270)

The claimant was injured in an accident on December 1, 2015. She applied for NEBs, and was denied on May 30, 2016. The insurer raised a preliminary issue of whether the claim was barred due to the expiry of the limitation period. Claimant’s counsel conceded that the application was filed late, on March 21, 2019, almost 10 months after the presumptive two year limitation period. However, Adjudicator Kaur held that the claimant met her onus in demonstrating that the limitation period should be extended, and she extended the limitation period to allow the application to proceed. The adjudicator found that the claimant had a bona fide intention to appeal based on the claimant’s miscommunication with their counsel, and the filing of multiple disability certificates. Adjudicator Kaur held that the 10 month delay did not blindside the insurer as they were actively adjusting the claim, and that the delay is mitigated by the fact that the claimant was conducting CAT assessments throughout that period. Lastly, Adjudicator Kaur held that the insurer would not be prejudiced by the appeal of the denial for benefits, and that there was sufficient evidence that the appeal had merit, given the finding that the claimant was catastrophically impaired.

Z .R. v. Gore Mutual Insurance Company (18-000017)

The claimant applied to the LAT seeking entitlement to attendant care benefits in the amount of $8,280.86 per month, various medical benefits, and the cost of examinations (including $11,250.00 for CAT assessments). The claimant had been declared catastrophically impaired in a previous LAT decision. As a preliminary issue, the insurer argued that pursuant to s. 56 of the SABS the claimant was barred from proceeding with his application for ACBs for failing to dispute a denial of the benefit within the two-year limitation period. Adjudicator Hines decided that the claimant was not barred from applying for ACBs. While Adjudicator Hines agreed with the insurer that a partial approval of ACBs triggered the limitation clock and the application was made two years after the partial approval, Adjudicator Hines found that the limitation period did not apply based on the guidance outlined in the Ontario Court of Appeal decision in Tomec. With regards to whether the claimed ACBs were reasonable and necessary, Adjudicator Hines held that being catastrophically impaired does not necessarily entitle a claimant to the maximum available under the SABS and found that the claimant did not meet the burden of proving that he required 24/7 supervision. Adjudicator Hines analyzed the various Form 1s and found that the claimant was entitled to reduced amounts for ACBs during two specific time periods. With regards to medical benefits, Adjudicator Hines found that the claimant was entitled to the disputed physiotherapy and psychological treatment as well as a functional abilities assessment. The proposed CAT assessments were partially reasonable and necessary in the amount of $4,200.00. Adjudicator Hines noted that not all the assessments were relied on at the previous hearing, the amount proposed for some assessments was above the $2,000 cap, and the claimant failed to articulate how some of the assessments were reasonable and necessary. The claimant was not entitled to the amount claimed for mileage related to occupational therapy treatment. Adjudicator Hines decided not to address the claimant’s submissions related to housekeeping benefits because entitlement to housekeeping benefits was not listed as an issue in dispute in previous LAT orders scheduling the hearing.

Belanger v. Intact Insurance Company (19-013755)

The insurer requested reconsideration of the Tribunal’s earlier decision which held that the claimant was not statute barred pursuant to s. 56 of the Schedule. In the initial decision, the Tribunal found that the delivery of the initial IRB denial letter dated March 26, 2015, despite being an adequate stoppage letter, was not done in accordance with s. 64 of the Schedule as the claimant subsequently retained counsel on June 20, 2015. The initial denial letter was not delivered to counsel until February 15, 2019. The claimant submitted his application on November 27, 2019. As such, the Tribunal initially determined that the application for IRBs fell within the effective limitation period of February 14, 2021. On reconsideration, Adjudicator Logan found that the Tribunal made an error. Adjudicator Logan held that s. 64 of the Schedule does not include a requirement to re-deliver a notice to counsel after they’ve been retained, and that the limitation period applied

Ladouceur v. Intact Insurance Company (2022 ONSC 5206)

The claimant sought judicial review of the Tribunal’s decision that the limitation period barred the claim for NEBs, and the Tribunal’s decision not to extend the limitation period under section 7 of the LAT Act. The Court dismissed the matter, holding that judicial review was only warranted in rare circumstances. The claimant chose not to appeal the decision under the Insurance Act, which provides for a statutory appeal on points of law. In essence, the claimant was requesting that the Court reweigh the medical evidence regarding the claimant’s mental capacity to form an intention to dispute NEBs. The Court was not persuaded that the Tribunal acted in an unfair or prejudicial manner.

Tamayo v. Travelers Insurance (20-014625)

The claimant disputed entitlement to IRBs and 10 treatment plans via a LAT Application filed on December 9, 2020 and a hearing was arranged to commence in November of 2022. The insurer filed a motion and raised a limitation defence under s. 56, arguing that the claimant failed to challenge the denial of IRBs within the two year limitation period. The claimant admitted that the Application was filed late, but requested that the LAT use s. 7 of the LAT Act to extend the time period. IRBs were denied by letter dated May 25, 2018, however the deemed arrival of the letter did not occur until June 1, 2018, which the insurer did not contest. As such, the two-year limitation mark would be June 1, 2020. Adjudicator Mazerolle applied s. 2 of O. Reg. 73/20 (the COVID regulation tolling limitation periods), meaning that the deadline to file a LAT Application was deemed to be December 1, 2020 with the extension period applied. The claimant had filed their application on December 9, 2020, eight days after the extended limitation period had lapsed. Adjudicator Mazerolle used s. 7 of the LAT Act to allow the late filing of the Application, noting that a delay of eight days was not excessive, that a November 12, 2020 letter requesting the AB file toward filing a LAT Application was an intent to appeal the IRB denial, and that there appeared to some merit to the claimant’s case, including a letter noting approval for CPP disability benefits in late 2020. While Adjudicator Mazerolle did admit that the insurer would be prejudiced from the missed limitation period, a delay of eight days would not be significant enough prejudice to not extend the limitation period.

Landa v. The Dominion of Canada General Insurance Company (19-011699)

This is a reconsideration decision. In the initial decision the LAT barred the claimant from proceeding with claims for benefits because she applied to the LAT outside of the limitation period. The LAT further determined that it lacked discretion to extend the limitation period under s. 7 of the LAT Act. The reconsideration hearing proceeded because the state of the law changed after the LAT hearing decision, when the Divisional Court determined that the LAT does have jurisdiction to extend the limitation period under s. 7 of the LAT Act. On reconsideration, Vice-Chair McGee found that the claimant had not established grounds for an extension of the limitation period. In finding that the claimant did not establish a bona fide intention to appeal, Vice-Chair McGee rejected the claimant’s argument that she was delayed in filing the LAT application due to ineffective representation by counsel and be causing she was engaging in settlement negotiations with the insurer. Vice-Chair McGee found that delays in filing the LAT application between 6 months and 10 years were significant and prejudicial to the insurer. The reconsideration was dismissed.