Insurer cannot rely on lack of Treatment Plan to deny rehabilitation benefits when it failed to assist the insured.
The applicant was injured in a motor vehicle accident and sought funding for a four-year university teaching degree as a vocational rehabilitation measure under section 15 of the Statutory Accident Benefits Schedule.
The insurer denied the claim on the basis that the applicant failed to submit a Treatment Plan (OCF-18) prior to incurring the expenses, as required by section 38.
The arbitrator held that the insurer could not rely on the applicant's failure to submit a Treatment Plan because the insurer breached its duty under section 32(2)(c) to assist the applicant in applying for benefits and failed to adjust the claim in good faith.
The arbitrator awarded the applicant the costs of two years of university tuition and books, plus interest and a 35% special award due to the insurer's unreasonable withholding of benefits.
OFSCDRSOntario Financial Services Commission - Dispute Resolution ServicesFeb 21, 2014
