This is a preliminary issue decision addressing two main issues: 1) Is the applicant an “insured person” as defined in s. 3(1) of the SABS, and 2) Does the LAT have jurisdiction under s. 280 of the Insurance Act in this matter? The claimant, an Ontario resident, was a pedestrian involved in a serious pedestrian-motor vehicle accident in New York state in July 2022. The vehicle that struck her was insured by the respondent (the insurance policy was issued to a resident of New York in accordance with the legislative authority of the state of New York). The applicant applied for accident benefits via an OCF-1 in August 2022. The claim was accepted at that time, and the claimant began receiving SABS benefits. In October 2022, the insurer advised the claimant that she was not entitled to SABS benefits, and the insurer would provide her coverage of $50,000 USD in accordance with the statutory obligations of the state of New York. in February 2023, the respondent advised the claimant that the $50,000 USD limit was nearly exhausted, and the file would be closed when it was exhausted. In May 2023, the claimant submitted an OCF-19 for CAT designation. The respondent advised that CAT-level benefits were not available as the claimant was not entitled to SABS benefits. The claimant proceeded to the LAT to dispute the denial. The claimant submitted that the respondent was estopped from denying entitlement to SABS benefits as it initially chose to adjust and pay benefits pursuant to the SABS. The respondent submitted that the claimant was not an “insured person” as she was not insured under any Ontario motor vehicle insurance policy and the accident occurred outside of Ontario. The respondent further submitted that the LAT cannot assume jurisdiction where the claimant was never an “insured person” and equitable principles cannot override statutory ineligibility or be evoked to create an obligation for the respondent to pay SABS benefits. Vice-Chair Morissette found 1) the LAT has jurisdiction to consider equitable remedies, including estoppel; 2) through the doctrine of estoppel by convention, the claimant was an “insured person” pursuant to the SABS; and 3) the LAT had jurisdiction to determine the application.
