Category: Limitation Period

F.S. v. Aviva Insurance Company (17-002313)

The claimant sought entitlement to various medical benefits. Adjudicator Sewrattan dismissed all of the claims, holding that the claimant had not demonstrated that the proposed treatment was reasonable and necessary. He also noted that the claimant had refused to provide her collateral benefits entitlement information and that he was unable to determine if any of the benefits would have been payable by the insurer. Finally, the adjudicator ruled that one proposed assessment was barred by the two-year limitation period.

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.

S.K. v. Allstate Insurance Company of Canada (16-004212)

The claimant sought entitlement to accident benefits. The insurer raised a limitations objection and relied on the letter holding the claimant in section 33 non-compliance as the triggering document. Adjudicator Chloe Lester determined that a refusal to pay a benefit from a section 33 notice letter can trigger a limitation objection. A distinction was made between a letter requesting information and a letter denying payment because of failing to provide information – the latter being able to trigger a limitation period. The claimant did not provide a reasonable explanation for not providing the requested information and it was therefore determined that the claims were barred due to the limitations provision.

I.A. v. Unifund Claims Inc (17-000785)

The claimant sought entitlement to a number of treatment plans. The insurer asserted a MIG position and also raised a limitation defense to one of the treatment plans. Adjudicator Billeh Hamud reviewed the denial letter of the insurer and found it to be clear and unequivocal. However, Adjudicator Hamud also noted that the claimant established a pre-existing injury that prevented recovery within the MIG; namely chronic pain from a previous MVA. Accordingly, the non-limitation barred treatment plans were found payable.

G.P. v. Aviva Insurance Company of Canada (16-000726)

The insurer appealed the Tribunal decision that a 2006 denial of income replacement benefits was not valid. Executive Chair Lamoureux agreed with the insurer and held that the Tribunal’s decision was a substantial error in law. She wrote that the denial had clearly and unequivocally communicated to the claimant that her entitlement to further income replacement benefits had been denied, and provided the claimant with the dispute process. Further, Executive Chair Lamoureux held that the claimant’s re-application for income replacement benefits in 2015 did not create a second triggering event for the limitation period. The claim for income replacement benefits was therefore barred.

G.P. v. Aviva Insurance Company of Canada (16-000726)

The insurer appealed the Tribunal decision that a 2006 denial of income replacement benefits was not valid. Executive Chair Lamoureux agreed with the insurer and held that the Tribunal’s decision was a substantial error in law. She wrote that the denial had clearly and unequivocally communicated to the claimant that her entitlement to further income replacement benefits had been denied, and provided the claimant with the dispute process. Further, Executive Chair Lamoureux held that the claimant’s re-application for income replacement benefits in 2015 did not create a second triggering event for the limitation period. The claim for income replacement benefits was therefore barred.

M.A. v. Intact Insurance Company (16-003510)

The claimant sought entitlement to attendant care benefits. The insurer asserted the claim was barred due to the limitations provisions. The claimant challenged the denial letter of the insurer. Adjudicator Therese Reilly held that the insurer’s denial was not clear and unequivocal. The letter relied upon by the insurer was a suspension of benefits for failing to attend an IE. Moreover, the insurer’s correspondence highlighted that should the claimant attend the IE, it would reconsider its position on attendant care benefits. Adjudicator Reilly drew a distinction between letters suspending benefits and those denying benefits. In this matter the insurer failed to provide a clear and unequivocal denial; the claimant could proceed with the claims for attendant care.

O.A. v. TD General Insurance Company (16-003897)

The claimant sought entitlement to income replacement benefits. The insurer denied the benefit based on the claimant being outside of the limitation period. The insurer also asserted that a completed disability certificate was not submitted within two years of the MVA, pursuant to section 36 and sought to have the application dismissed. On review of the documentary evidence, Adjudicator Deborah Neilson held that the application could proceed as there was not a clear and unequivocal denial of the benefit to trigger the limitation period. Adjudicator Neilson also noted that strict compliance requiring a completed disability certificate was not what the Legislature intended. If information lacking on one document was found elsewhere, it was to be read with it. Moreover, if there was information missing that was critical to adjust the claimed benefit, the insurer was to request it. Accordingly, the claimant could bring an IRB claim before the LAT.

S.Y. v .Aviva General Insurance Company (16-004549)

The claimant sought entitlement to medical benefits. Some of the treatment plans were not included as original issues in dispute, others were already paid by the insurer. Adjudicator Anna Truong reviewed the medical evidence and determined that two treatment plans were reasonable, while a psychological treatment plan was not. Other treatment plans were denied due to limitations. Interest was awarded on the two reasonable treatment plans, if there was any overdue payment.

V.A. v. Co-operators General Insurance Company (17-001327)

The insurer requested a preliminary motion to determine whether the claimant was barred from seeking income replacement benefits due to the limitation period. Adjudicator Neilsen held that the limitation period did not apply because the claimant was only deemed to have received a denial from the insurer five days after it was mailed her (per section 64 of the SABS).