Category: Limitation Period

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.

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.

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).

The claimant sought entitlement to attendant care and housekeeping benefits. The insurer asserted a limitations position. The claimant’s last Form 1 was submitted just prior to the 104 week anniversary of the MVA. The insurer informed the claimant that a CAT determination would be needed in order for payment beyond the 104 week period. Nearly five years later, the claimant submitted a CAT application and was ultimately found to have suffered a catastrophic impairment. The claimant then sought payment of attendant care and housekeeping from the date of the last Form 1 submitted. The insurer denied payment saying the claimant had not disputed the denial at the date of the initial denial of benefits. The insurer asserted that just because CAT applications do not have a time limit, it does not release the claimant from the limitations period. Although the claimant argued certain boxes were not checked in the OCF-9, Vice Chair Heather Trojek determined that the initial denial of the insurer was clear and unequivocal per the Supreme Court of Canada’s reasons in Smith v Co-operators. While consumer protection was considered, it was held that binding Ontario Court of Appeal decisions and “other objectives” must also be balanced against the principle. As a result of this finding, and given the LAT application was approximately six years after the denial, Vice Chair Trojek found the limitation period applicable.