K.G. v. Certas Direct Insurance Company (16-003633)

The insurer argued that the claimant failed to apply to the LAT within two years of the refusal to pay in accordance with section 56 of the SABS. The claimant argued the insurer’s explanation of benefits (EOB) did not constitute a denial in compliance with the SABS. Adjudicator Watt held the EOB did not constitute a denial and that the claimant could proceed with her claim. There was no evidence that the insurer provided the claimant the information and forms required in response to her application for benefits. Stating in the EOB that the claimant “did not qualify” for a benefit does not amount to refusing to pay a benefit that has been claimed.