Explanation of Benefits capping benefits under Pre-Approved Framework is not a clear and unequivocal denial.
The applicant was injured in a motor vehicle accident and received income replacement benefits (IRB) until returning to work.
Over nine years later, the applicant sought reinstatement of the IRB.
The insurer argued the claim was statute-barred, relying on a 2006 Explanation of Benefits (EOB) as a denial, and alternatively argued the applicant failed to apply within 104 weeks.
The Tribunal found the EOB was a statement of statutory entitlement under the Pre-Approved Framework, not a clear and unequivocal denial.
The Tribunal also found no requirement to apply within 104 weeks, and regardless, the initial claim was made within that period.
The preliminary motion to dismiss was denied.
G. P. v. Aviva Insurance Company of Canada, 2017 CanLII 12605