Category: Reconsideration

Aviva Insurance Canada v G.P. (16-004349)

The claimant sought reconsideration of the Tribunal’s decision ordering him to repay IRBs to the insurer. The insurer had voided the claimant’s insurance policy after he had failed to notify the insurer of a change in a risk material to that policy. The claimant argued that a third party was at fault for the failure to advise the insurer of the material change; he submitted documents at the reconsideration hearing to support this contention, which had not been previously disclosed. Executive Chair Lamoureux upheld the Tribunal’s decision. She refused to consider the new documents as Rule 18.2(c) only allowed for parties to correct evidence already adduced at a hearing. Executive Chair Lamoureux further held that the documents, if they had been admitted, supported a finding that the claimant was aware of his responsibility to keep the insurer apprised of any material changes that affected his policy, and that he intentionally failed to do so.

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

The insurer sought reconsideration of the Tribunal’s decision that the claimant’s failure to include a police report was not fatal to his application to the Motor Vehicle Accident Claims Fund. Executive Chair Lamoureux upheld the Tribunal’s decision. Despite an application being incomplete, section 32 triggered the insurer’s responsibility to determine whether a benefit was payable. Executive Chair Lamoureux referred to legislation and jurisprudence regarding priority disputes when concluding that applications could be considered complete if they were functionally adequate for their legislated purpose. Executive Chair Lamoureux further held that the insurer was precluded from taking the position that the MIG applied and that the disputed treatment plans were automatically payable. However, the claimant’s application for NEBs was dismissed for a lack of evidence establishing entitlement.

A.S. v. Pafco Insurance (16-003683)

The claimant sought reconsideration of the Tribunal’s decision to deny the claim for ongoing IRBs. The claimant requested reconsideration on the basis that the Tribunal denied him natural justice and procedural fairness. Associate Chair Batty agreed with the claimant that the Tribunal had overlooked or mischaracterized parts of the claimant’s evidence at the LAT hearing. Associate Chair Batty ordered that the application would be reheard in writing and be limited to considering anew evidence and submissions already provided by the parties.

V.S. v. Travelers Insurance Company of Canada (17-001670)

The claimant sought reconsideration that he was not entitled to treatment outside of the MIG. With the insurer having approved both treatment plans in dispute and removing the claimant from the MIG in advance of the reconsideration hearing, the single issue to be decided was whether the claimant was entitled to interest on the insurer’s payment of the outstanding benefits. Executive Chair Lamoureux held that it did. Pursuant to sections 51(1) and (2) of the SABS, an insurer is required to pay interest on any overdue payments of a benefit. The insurer had agreed that the amounts of the treatment were payable and therefore was required to pay interest in accordance with the SABS on any overdue payments.

P.R. v. Aviva Canada Insurance (16-002782)

The insurer requested reconsideration of the LAT’s decision to deny its request for costs, arguing that the claimant’s failure to address serious evidentiary issues throughout he proceeding amounted to frivolous and vexatious conduct warranting a costs award. Associate Chair Batty denied the request. While the LAT did not explicitly apply the definitions of frivolous and vexatious in its decision, the claimant’s actions did not amount to such conduct. The claimant’s application may have been weak, but he filed hundreds of pages of evidence in support of his position and based on that evidence, put forth some rational foundation to advance his position. He was not acting without reasonable or probable cause.

T.F. v. Peel Mutual Insurance Company (16-003316)

The claimant sought reconsideration of the Tribunal’s decision that she was barred from seeking entitlement to two treatment plans, arguing that the insurer’s denials did not provider the requisite medical reasons. Executive Chair Lamoureux agreed with the claimant and overturned the decision. She held that the insurer’s medical reasons had to engage the specific details about the claimant’s condition, and should be adequate enough to allow an unsophisticated person to understand them and make an informed decision. She reasoned that the insurer’s denials in this case failed to cite the specific documentation upon which the insurer was relying in denying the proposed benefits.

T.F. v. Peel Mutual Insurance Company (16-003316)

The claimant sought reconsideration of the Tribunal’s decision that she was barred from seeking entitlement to two treatment plans, arguing that the insurer’s denials did not provider the requisite medical reasons. Executive Chair Lamoureux agreed with the claimant and overturned the decision. She held that the insurer’s medical reasons had to engage the specific details about the claimant’s condition, and should be adequate enough to allow an unsophisticated person to understand them and make an informed decision. She reasoned that the insurer’s denials in this case failed to cite the specific documentation upon which the insurer was relying in denying the proposed benefits.

R.P. v. Wawanesa Insurance Company (16-002947)

The claimant requested reconsideration of the LAT’s decision in favour of the insurer’s denial of entitlement to certain medical benefits, expenses for prescription medication, and interest. He argued that the LAT violated procedural fairness by failing to either refer to or consider certain medical records in its decision. Executive Chair Lamoureux denied the request for reconsideration. She found that while the LAT’s decision did not explicitly refer to all of the documents, it did state that it considered all of the submitted documents and summarized those that were relevant to its findings. In any event, the records did not support a different result.

A.L. v. The Personal Insurance Company (17-002582)

The Tribunal initially decided that the claimant was precluded from applying to the LAT in light of his non-attendance at multiple insurer examinations. Associate Chair Batty initiated a reconsideration on his own initiative to remedy a breach of procedural fairness in the preliminary issue hearing. In its reasons, the LAT had described how the respondent’s submissions relied upon affidavit evidence which had not been filed. Counsel for the respondent subsequently provided proof that the affidavit in question had been filed. It was not provided to the adjudicator as a result of an administrative error. Associate Chair Batty held that the respondent had been denied procedural fairness and remitted the matter to be reheard on the LAT’s full record.

A.L. v. The Personal Insurance Company (17-002582)

The Tribunal initially decided that the claimant was precluded from applying to the LAT in light of his non-attendance at multiple insurer examinations. Associate Chair Batty initiated a reconsideration on his own initiative to remedy a breach of procedural fairness in the preliminary issue hearing. In its reasons, the LAT had described how the respondent’s submissions relied upon affidavit evidence which had not been filed. Counsel for the respondent subsequently provided proof that the affidavit in question had been filed. It was not provided to the adjudicator as a result of an administrative error. Associate Chair Batty held that the respondent had been denied procedural fairness and remitted the matter to be reheard on the LAT’s full record.