M.A. v. Intact Insurance Company (16-003510)

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.