Category: Repayment

Applicant v. Unifund Assurance Company (16-003709)

The claimant sought entitlement to IRBs and ACBs. The insurer sought repayment of IRBs paid for a period that the claimant was working. Adjudicator Bickley denied entitlement to both IRBs and ACBs. She held that the claimant’s return to work shortly after the accident and frequency gym attendances suggested that the claimant did not suffer a substantial inability to engage in her employment, and that she did not require assistance with personal care. Adjudicator Bickley also held that the claimed attendant care expenses were not incurred because the claimant’s daughter had not submitted any evidence of an economic loss. In terms of the claim for repayment, Adjudicator Bickley allowed the repayment issue to be added as an issue at the beginning of the hearing. The claimant’s representative acknowledged an overpayment for the period which the claimant had returned to work after the accident. The claimant was ordered to repay $2,984.59 in IRBs plus interest.

Applicant v. Certas Home and Auto Insurance Company (17-001090)

The claimant disputed his entitlement to income replacement benefits (IRBs). The insurer sought repayment for overpayment of IRBs in the amount of $16,000. Adjudicator Bickley dismissed the claimant’s claim for IRBs and the insurer’s repayment request. Adjudicator Bickley dismissed the claimant’s special award claim and the insurer’s cost award claim. Adjudicator Bickley dismissed the claimant’s dispute for IRBs on the basis that the claimant returned to her full-time pre-accident employment after the accident and then went to school to become a PSW. Adjudicator Bickley concluded that the claimant’s ability to return to work and then attend school and become a PSW persuaded her (Adjudicator Bickley) that the claimant did not meet the pre-104 week IRB test. With respect to the insurer’s IRB repayment request, Adjudicator Bickley dismissed the insurer’s dispute on the basis that the insurer paid the claimant IRBs even though it was aware of issues with the claimant’s IRB eligibility and therefore, concluded that the insurer did not pay the claimant in error.

Certas Direct Insurance Company v. T.T. (17-000272)

The insurer sought repayment of income replacement benefits, asserting the claimant failed to disclose post-accident income. The claimant did not participate in the hearing. Adjudicator Sandeep Johal determined that the claimant was indeed employed during the payment period, and that the insurer had given adequate and timely notice regarding repayment. Furthermore, the claimant committed a willful misrepresentation when he informed his IE assessors that he did not return to work. Accordingly, the insurer’s claim for repayment was allowed with interest.

Aviva Insurance Canada v. “Mr.P” (16-004349)

The claimant applied for and received various accident benefits from Aviva, including $14,514 in IRBs. Aviva subsequently voided the policy because the claimant failed to disclose that his partner, who had a poor driving record, had moved in with him one year prior to the accident. Aviva applied for an order requiring the claimant to repay the $14,514 in IRBs and to reimburse for the $5,537 expended on IEs to address the claimant’s entitlement to IRBs. Adjudicator Shapiro concluded that Aviva was entitled to repayment of the $14,514 in IRB, but not to reimbursement of the $5,537 related to the IEs. He found that, on the balance of probabilities, the claimant intentionally failed to disclose materials information, and Aviva did not reasonably know of the information through other means. However, regardless of whether there is an intentional failure to disclose, IE expenses are not subject to repayment under section 52.

Aviva Insurance Company of Canada v. N.S. (17-001880)

The insurer sought repayment of IRBs after the claimant was retroactively approved for LTD benefits. The claimant argued that the insurer was only entitled to recoup the repayment by way of deduction from her weekly IRB payments. The insurer argued that it was entitled to an order for lump sum repayment. Adjudicator Mather agreed with the insurer. She held that the insurer had made its request for repayment within 12 months of the overpayment, and that the insurer was entitled to an order for the lump sum repayment. The SABS did not restrict the insurer to only weekly recovery by way of IRB deductions. The insurer was also entitled to interest on the repayment.

Aviva Canada Inc. v. R.R. (16-004445)

The insurer appealed the dismissal of its repayment claim, which had been denied because there was no proof that the claimant was given the notice of repayment. Executive Chair Lamoureux held that there had been a breach of procedural fairness because the issue of whether a notice was provided to the claimant was not addressed in the written materials, and the insurer had failed to include the repayment notice in its materials due to “administrative oversight.” The matter was remitted for rehearing.

Aviva Canada Inc. v. R.R. (16-004445)

The insurer appealed the dismissal of its repayment claim, which had been denied because there was no proof that the claimant was given the notice of repayment. Executive Chair Lamoureux held that there had been a breach of procedural fairness because the issue of whether a notice was provided to the claimant was not addressed in the written materials, and the insurer had failed to include the repayment notice in its materials due to “administrative oversight.” The matter was remitted for rehearing.

Applicant v. ACE INA Insurance (17-001422)

The claimant sought entitlement to various medical benefits; the insurer sought repayment of IRBs due to overpayment of the weekly quantum. Adjudicator Treksler held that the claimant failed to provide evidence that the claimed physical therapy and assessments were reasonable and necessary. She ordered the claimant to repay the overpayment in IRBs, stating that the insured had complied with all of the requirements of section 52 and the claimant had not shown that any exception to repayment applied.

Aviva Insurance Company of Canada v. A.M. (16-001014)

The insurer sought reconsideration of the Tribunal’s denial of repayment of IRBs. The request was based on the claimant receiving disability benefits. The claimant had not informed the insurer of his receipt of disability benefits, and the insurer subsequently made a request for repayment of IRBs totalling $4,414.29. The Tribunal had originally denied repayment reasoning that insufficient evidence of the overpayment was placed before the Tribunal. Executive Chair Lamoureux overturned the decision and awarded the request for repayment. Executive Chair Lamoureux held that the Tribunal had failed to consider evidence before it, and misconstrued other records before it.

Aviva Insurance Company of Canada v. A.M. (16-001014)

The insurer sought reconsideration of the Tribunal’s denial of repayment of IRBs. The request was based on the claimant receiving disability benefits. The claimant had not informed the insurer of his receipt of disability benefits, and the insurer subsequently made a request for repayment of IRBs totalling $4,414.29. The Tribunal had originally denied repayment reasoning that insufficient evidence of the overpayment was placed before the Tribunal. Executive Chair Lamoureux overturned the decision and awarded the request for repayment. Executive Chair Lamoureux held that the Tribunal had failed to consider evidence before it, and misconstrued other records before it.