Category: Special Award

The claimant was seriously injured in an accident and received benefits from his insurer as a result. The claimant applied to the LAT seeking an award under s. 10 of Regulation 664, submitting that the insurer acted in bad faith to prevent him from applying for additional benefits. Specifically, the claimant argued that the insurer failed to inform him of benefits which were available and failed to advise that he obtain legal counsel. Adjudicator Evans concluded that the claimant failed to establish that the insurer acted in bad faith. The evidence before the LAT confirmed that a representative of the insurer met with the claimant after the accident and provided an information packet containing all of the necessary information to make a claim. Adjudicator Evans further highlighted that the SABS does not require an insurer to recommend legal counsel but may require that they provide notice that an insured person is entitled to legal representation at an examination under oath. The claimants application was dismissed.

The claimant’s father was fatally injured in an automobile accident which led the claimant to develop psychological injuries and claim benefits pursuant to the SABs. A section 44 examination concluded that the proposed psychological treatment sought by the claimant was reasonable and necessary; however an incorrect fax number was used to send correspondence approving treatment. The claimant applied for an award pursuant to s. 10 of O. Reg 664 due to the insurer’s error. Adjudicator Norris found that the claimant was not entitled to an award as the insurer’s behaviour did not amount to unreasonable withholding or the delay of the payment. Adjudicator Norris emphasized that insurers are not to be held to the standard of perfection, and mistakes are not errors that warrant the grant of an award.

The Tribunal determined that the claimant was not entitled to an award under s. 10 of O. Reg 664. The claimant had argued that the insurer’s denial of a treatment plan was unreasonable as it had relied on an insurer examination that was contrary to the available medical records. Vice-Chair Marzinotto found that the medical evidence included in the report was consistent with the claimant’s records and that it was therefore reasonable for the insurer to rely on the report. There is a high threshold for entitlement to an award under O. Reg. 664. The claimant failed to demonstrate that the insurer had either unreasonably withheld or delayed the payment of a benefit to which he was entitled.

The claimant sought a special award from the insurer relating to the denial and subsequent approval of a psychological assessment prior to a LAT hearing. Adjudicator Hines determined that the insurer unreasonably withheld and delayed payment of a treatment plan for the psychological assessment. As a result, she determined that a special award of 25 percent of the treatment plan was appropriate. The Tribunal considered the length of the delay, the blameworthiness of the insurer’s conduct, the vulnerability of the insured person, the harm or potential harm directed at the insured person, the need for deterrence, and any advantage wrongfully gained by the insurer from the misconduct. The Adjudicator found the length of the delay the most aggravating factor as the insurer had denied the treatment plan without any rationale and did not approve the benefit for almost two years from the date it was submitted. Further, the Adjudicator found that the claimant was particularly vulnerable as she was a minor when the treatment plan was initially denied. An insurer ought to use extra care when handling treatment plans for minors and be clear with its rationale for denial. The Adjudicator reduced the quantum of the special award because the claimant failed to demonstrate that she had been prejudiced by the insurer’s conduct, and because the insurer approved the treatment plan eight months before the hearing.