The claimant was in an accident in September 2015. He was paid IRBs until December 2015. In a December 30, 2015 EOB letter, the insurer notified the claimant that: “Your Income Replacement Benefit has been stopped on December 2, 2015, as you returned to work full-time on December 2, 2015. No further Income Replace Benefit will be paid after this date.” In July 2018, the claimant applied to the insurer to resume his IRBs on the basis that he was forced to stop working as a result of accident-related injuries. The insurer denied the claim, stating: “Please refer to our explanation of benefits dated December 30, 2015. Our position remains unchanged.” In September 2018, the claimant applied to the LAT seeking entitlement to IRBs. The insurer argued that the claim for IRBs was time-barred because the claimant failed to apply to the LAT within two years of the December 30, 2015, IRB termination letter. The issue before Adjudicator Boyce was whether the December 2015 letter complied with the requirement in s. 37(4) of the SABS to provide “medical and any other reasons” for the decision to terminate IRBs. Adjudicator Boyce found that the insurer was not required to provide medical reasons for its denial of IRBs under s. 37(4), the December 2015 letter was a proper refusal under s. 56 of the SABS, and the limitation period had expired. A request for reconsideration was dismissed. The claimant appealed to the Divisional Court. Justice Mandhane allowed the appeal, finding that the December 2015 letter did not comply with s. 37(4) or case law requirements for medical and other reasons because it did not refer at all to the claimant’s medical condition or the specific provisions of the SABS that it relied upon to deny benefits. Justice Mandhane held that “insurers are not required to manufacture medical reasons where they do not exist, but to be explicit as to whether or not such medical reasons support denying or limiting coverage. If they explicitly deny having medical reasons to support their determination, the Applicant will come to understand that their disability or “impairments” is not currently in issue.” Pursuant to the Court of Appeal decisions in Sietzema and Bonaccorso, the insurer argued that even if the reasons in the December 2015 letter were deficient, the limitation period was triggered because the denial was clear and unequivocal. Justice Mandhane found that “Sietzema and Bonaccorso are of limited assistance because the Court was considering the proper interpretation of the pre-2010 SABS, which did not explicitly require ‘medical and any other reasons’ as part of the insurer’s decision to deny IRBs. The Court of Appeal’s narrow focus on the clarity of the insurer’s ultimate decision to deny benefits cannot be justified in the face of the legislature’s 2010 amendments….” Justice Mandhane found that the December 2015 letter was not a valid refusal and did not trigger the running of the limitation period.
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