The insurer brought a motion for summary judgment seeking dismissal of the insured’s statutory accident benefits action as statute‑barred under s. 281.1 of the Insurance Act.
The insured had submitted an Application for Determination of Catastrophic Impairment (OCF‑19), to which the insurer responded with an Explanation of Benefits (OCF‑9) stating the insured had not sustained a catastrophic impairment and therefore did not qualify for increased benefits.
The insured argued that denial of catastrophic impairment status alone does not constitute a refusal to pay a benefit and therefore does not trigger the limitation period.
The court distinguished prior authority and held that the wording of the OCF‑9 expressly communicated that increased benefits were not payable, which constituted a refusal to pay benefits.
Accordingly, the two‑year limitation period began to run from that denial and the claim was commenced out of time.
