Tribunal File Number: 17-000388/AABS
In the matter of an Application pursuant to subsection 280(2) of the Insurance Act, RSO 1990, c I.8., in relation to statutory accident benefits.
Between:
D.W.
Applicant
and
The Co-Operators
Respondent
DECISION
Adjudicator: Cezary Paluch
PPEARANCES:
For the Applicant: Arthur R. Camporese, Counsel
For the Respondent: David Raposo, Counsel
Held in writing: April 24, 2017
OVERVIEW:
The applicant, “DW”, was injured in an automotive accident on September 17, 2013 and sought an income replacement benefit (IRB) pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (the "Schedule").
DW submitted an Application for dispute resolution services to the Licence Appeal Tribunal - Automobile Accident Benefits Services (the “Tribunal”) regarding his entitlement to an income replacement benefit (“IRB”).
At the case conference held on March 21, 2017, the respondent, The Co-Operators (“Co-Op”), raised a preliminary issue that the applicant did not apply for the income replacement benefit within 104 weeks of the accident. A hearing in writing was ordered to deal with both the preliminary issue and the main issue regarding entitlement to the IRB.
All submissions and evidence were filed with the Tribunal. A review of those documents forms the basis of this decision.
PRELIMINARY ISSUE:
- Is the applicant precluded from proceeding with a claim for income replacement benefits because he did not apply for the benefit within 104 weeks of the accident?
SUBSTANTIVE ISSUE:
- Is the applicant entitled to receive a weekly income replacement benefit in the amount of $400.00 per week for the period December 17, 2013, to date and ongoing?
RESULT:
For the reasons that follow, the applicant is not precluded from proceeding with his income replacement claim as he did apply for the benefit within 104 weeks of the accident.
The applicant’s claim for income replacement benefits is dismissed as he did not qualify for an income replacement benefit.
FACTS:
Chronology of Application for Income Replacement Benefit
- Based on the materials filed, I make the following findings regarding the chronology of the applicant’s claim for an income replacement benefit:
i. On September 17, 2013, the applicant was injured in a motor vehicle accident.
ii. On September 27, 2013, Co-Op sent the respondent a letter advising him of his rights to apply for various benefits and enclosed several blank forms including an Application for Accident Benefits (OCF-1) and Disability Certificate (OCF-3).
iii. On November 6, 2013, the applicant submitted an Application for Accident Benefits (OCF-1) to Co-Op, signed by him on October 24, 2013, indicating on page 6 that he sustained injuries as a result of the accident and was unable to return to work due to his injuries.
iv. On November 20, 2013, Co-Op sent another letter to the respondent acknowledging receipt of the Application for Accident Benefits and that the blank Disability Certificate (OCF-3) that was provided with the September 27, 2013, correspondence was forthcoming. This letter also advised that: “Once we are in receipt of the Disability Certificate we will advise you further with respect to your benefit entitlement.”
v. The applicant’s lawyer faxed the Disability Certificate (OCF-3) of Dr. C. dated October 10, 2013, to the respondent on December 17, 2013 (the “First Disability Certificate”) that did not confirm entitlement to IRBs.
vi. However, for unknown reason, the respondent apparently did not receive the First Disability Certificate until January 21, 2015. This was 15 months after the applicant had sent in the First Disability Certificate.
vii. On January 29, 2015, Co-op wrote to the applicant that they received the Disability Certificate from the applicant’s representative on January 21, 2015 and attached an Explanation of Benefits form.
viii. On or about February 1, 2017, an Application was received by the Licence Appeal Tribunal disputing the applicant’s entitlement to income replacement benefits. The date of denial with respect to the IRB was listed on the Application as January 29, 2015 (being the letter from Co-Op to DW enclosing the Explanation of Benefits form).
ix. On February 13, 2017, a second or updated Disability Certificate (OCF-3) of another doctor, Dr. MC. (the “Updated Disability Certificate”) indicated that the applicant was substantially unable to perform the essential tasks of his employment at the time of the accident as a result of and within 104 weeks of the accident. This was 3 years and 5 months post-accident.
x. On March 3, 2017, the respondent acknowledged receipt of the Updated Disability Certificate and advised the applicant that he still did not qualify for an income replacement benefit because he did not apply or qualify for the benefit within 104 weeks after the accident and that the disability certificate that was received 15 months post-accident did not indicate a substantial inability to do the tasks of his employment.
LAW AND ANALYSIS:
Preliminary Issue:
Is the applicant precluded from proceeding with a claim for an income replacement benefit (“IRB”) because he did not apply for the benefit within 104 weeks of the accident?
- To answer this question, I must determine whether: (i) the First Disability Certificate (OCF-3) was submitted to the respondent on December 17, 2013; and (ii) if the First Disability Certificate that was submitted complied with s. 36 of the Schedule.
i. Was a disability certificate submitted to the respondent on December 17, 2013?
Applicant’s Position
- The applicant’s position is that the First Disability Certificate was faxed to the respondent on December 17, 2013. The fax confirmation sheet and other correspondence from the insurer in the file confirm that the fax number used by the DW’s lawyer was the fax number of the respondent.
Respondent’s Position
The respondent’s position is that the First Disability Certificate dated October 10, 2013 was not received by Co-Op until 15 months later on January 21, 2015. Subsequently, by way of letter dated January 29, 2015, Co-op wrote to the applicant confirming receipt of the First Disability Certificate and enclosing an Explanation of Benefits stating that that no benefit is payable because Dr. C. confirms that you do not meet the disability test for this benefit.
After consideration and review of the submissions and evidence presented by both parties, I accept that the applicant’s lawyer did fax a disability certificate (OCF-3) to the insurer on December 17, 2013, based on the following documentary evidence before the Tribunal:
i. DW’s Affidavit dated April 6, 2017, at para. 42, states that: “The Disability Certificate of Dr. C.’s was faxed to the Insurer by my lawyer on December 11, 2013, after I paid Dr. Chan $105.00 for completing the OCF-3”1;
ii. an enclosure letter from DW’s lawyer to Ms. K. of Co-Op dated December 11, 2013, states: “Please find enclosed herewith a Disability Certificate (OCF-3) form dated October 13, 2013.”
iii. the applicant obtained a fax confirmation page or transaction report indicated that 6 pages were sent to 905-560-9422 at 9:43 a.m. on December 17, 20132;
iv. the fax cover page dated January 29, 2015 from Co-Op’s confirms that their fax number was 905-560-94223;
v. clinic notes and records of Dr. Chan confirmed that DW did attend for treatment with him in October 20134;
vi. invoice from Dr. C. in the amount of $100.00 for services rendered5;
vii. at the top of the page of the Disability Certificate it states: Return this form, and lists the “The Co-operators” as the recipient that the form should be sent to.
The respondent in their submissions state that it did not receive the First Disability Certificate until January 21, 2015 (despite it being dated October 10, 2013, 15 months earlier). I can only presume that it may have been inadvertently misplaced or lost and this is the reason that the insurer did not respond to it immediately. I queried whether the insurer’s faxes are automatically converted into electronic copies. I also questioned whether the fax machine was diligently attended to. Although I cannot know for certain based on the evidence, I cannot help but conclude that some human error occurred in this case. The respondent did not provide an Affidavit to provide an explanation regarding the circumstances of this apparent miscommunication between the parties or any evidence to the contrary. No evidence of a technical nature was adduced to explain how a fax confirmation page can indicate that a document was sent but was never received by the recipient.
Therefore, for the above reasons, on the balance of probabilities, I find as a fact that the applicant sent by fax the First Disability Certificate on December 17, 2013. I also find as a fact that the respondent was deemed to have received the First Disability Certificate. Therefore, I conclude that First Disability Certificate was submitted to the respondent on December 17, 2013, clearly within 104 weeks of the accident (as the issue has been put to me).
I must now deal with the issue whether the submitted First Disability Certificate was a completed disability certificate as required by section 36 of the Schedule.
ii. Did the applicant comply with section 36 of the Schedule?
Applicant’s Position
The applicant asserts that the Application (OCF-1) and the First Disability Certificate (OCF-3) comprise an application for an income replacement benefit within 104 weeks of the accident. The applicant states in their submission that the First Disability Certificate was misinterpreted by the insurer who did not undertake any medical or psychological assessments to determine if the DW was eligible to receive an income replacement benefit.
The applicant submits that the plain wording of s. 36 merely requires an insured to submit a completed disability certificate and does not require that the certificate confirm entitlement to IRB’s (or what the respondent refers to as a “positive certificate.”)
In the alternative, the applicant argues, that if DW was required to submit a “positive” disability certificate, the applicant seeks relief from forfeiture on the basis of imperfect compliance pursuant to section 129 of the Insurance Act.
In any event, even if there was non-compliance with s. 36, the applicant also argues that there is no requirement in the Schedule that the applicant needed to apply for income replacement within 104 weeks of the accident.
Respondent’s Position
The respondent disputes that the applicant applied for an IRB within 104 weeks of the accident because he did not submit a completed disability certificate with his Application in accordance with section 36 of the Schedule. More specifically, Co-Op maintains, the applicant did not submit a disability certificate confirming entitlement to IRB’s until February 16, 2017 (being 3.5 years post-accident)(this was an updated Disability Certificate).
Section 36 of the Schedule sets out what an applicant must submit to claim income replacement benefits. It states:
Application
- (1) In this section and section 37, “specified benefit” means an income replacement benefit, non-earner benefit, caregiver benefit or a payment for housekeeping or home maintenance services under section 23.
(2) An applicant for a specified benefit shall submit a completed disability certificate with his or her application under section 32. [emphasis added]
(3) An applicant who fails to submit a completed disability certificate is not entitled to a specified benefit for any period before the completed disability certificate is submitted. [emphasis added]
- The word “completed” is not defined term in s. 3 of the Schedule. However, section 67 of the Schedule is of assistance and states when a form is completed, as follows:
When form is considered completed
- Any document that is required by section 666 to be in a form approved by the Superintendent and to which subsection 64 (7) applies and any other document specified in a Guideline applicable for the purposes of this section is duly completed and includes all information required by this Regulation to be included in it if,
a) every field not identified on the form as an optional field is completed in accordance with subsection (2); and
b) if any field on the form that is identified as an optional field is completed, it is completed in accordance with subsection (2).
- If the form specifies the manner or the format in which a field is to be completed, completion of the field shall be in that manner and in that format.
An examination of the First Disability Certificate submitted by the respondent shows that a prescribed FSCO approved Form 1226E, effective 2010-09-01 was used by the applicant. It also shows that every field was filled in as per the instructions at the top of the form including Parts 1 to 3 by the applicant who signed it on October 7, 2013, and Parts 5 to 10 by Dr. C. who signed it on October 10, 2013 (no earlier than 10 business days of the date of the application which was October 24, 2013).
A significant part of the certificate (as far as entitlement to IRB’s is concerned) is found under Part 6 Disability Tests and Information, to the question: “Is the applicant substantially unable to perform the essential tasks of his employment at the time of the accident as a result of and within 104 weeks of the accident?” (the income replacement criterion), the doctor answered “N/A”, indicating that either DW did not meet the test for this benefit or this section was not applicable. In any event, the Disability Certificate did not support the claim for an IRB.
In their submissions, the respondent argues that a completed disability certificate means a certificate that confirms entitlement to IRBs. They also rely on section 36(3) of the Schedule that states that an applicant who fails to submit a completed disability certificate is not entitled to a specified benefit for any period.
I do not agree. In my view, s. 36 cannot be interpreted so narrowly in this manner for four main reasons.
First, in my view, the word “completed” cannot be equated to mean “positive.” If the legislature wanted a claimant to submit a “positive” certificate than the drafters surely would have used this terminology in the Schedule. They did not. The plain wording of s. 36 merely requires an insured to submit a completed disability certificate using the correct form and does not require that the certificate confirm entitlement to IRB’s (or what the respondent refers to as a “positive certificate”). For example, a document can still be completed if all of the fields are filled in (perhaps certain information is lacking or perhaps the information that was provided does not qualify a person for a particular benefit) but it does not render the certificate incomplete. All that is required by section 36 is that the fields be filled out and the disability certificate be signed by the applicant and the health practitioner in conjunction with section 67. With respect to the income replacement criterion, under Part 6 of the Disability Certificate, the health practitioner had one of 3 options or boxes to check off: 1) Yes; 2) No; or 3) N/A. Here, Dr. C. checked off N/A – in other words, he chose one of the three options that were available to him. Therefore, he completed that portion of the disability certificate and it cannot be said that the applicant did not comply with s. 36 of the Schedule.
Second, as I understand, the respondent’s position is that without an OCF-3 certificate that has the box regarding the disability checked off as “Yes”, then there is no completed disability certificate. Without such a disability certificate, there is no entitlement to the income replacement benefit. I do not accept this position as I find very restrictive with too much weight being placed on one question. A question that a health practitioner may not be able to answer at a particular point in time when he fills it the document. It also leaves the applicant’s health practitioner complete power to effectively negate a claim simply by means of checking the “no” box, or as in this case, the “N/A” box. This type of restraining approach is not in keeping with the overall objectives of the Insurance Act, which emphasizes consumer protection. Section 36 must be interpreted in a fair, liberal and purposive manner to achieve the objectives of protecting an insured’s rights to statutory accident benefits.
Third, the respondent did not deny the application for IRBs on the basis that it was incomplete. The respondent denied the request because it had decided the applicant did not meet the test for the benefit. In fact, the denial letter dated September 29, 2015, and Explanation of Benefit form, clarifies to the applicant that he does not meet the disability test to qualify for this benefit. Notably, it says nothing about the Disability Certificate being incomplete.
Finally, an OCF-3 disability certificate is not the sole factor to consider when determining whether a claimant meets the disability test for an income replacement benefit. In my view, a disability certificate is certainly an integral part of the entire application for an IRB but it is simply one piece of the evidence supporting a claim and not a decisive piece of the application. The focus throughout has to always be whether the claimant has demonstrated that he or she meets the relevant disability standard -- namely, for the first 104 weeks post-accident, a substantial inability to perform the essential tasks of his or her employment within 104 weeks of the accident.
In summary, I view the state of the law to be that a “completed disability certificate” need not be a “positive certificate” or a certificate that has to absolutely confirm entitlement to IRB’s. It merely has to be a “completed disability certificate” that conforms to the formalities required by s. 67 of the Schedule and the completion instructions on the actual OCF-3 form.
Therefore, with respect to the preliminary issue that has been put before me, I find that the applicant is not precluded from proceeding with a claim for income replacement benefits because he did submit by fax a disability certificate within 104 weeks of the accident and this certificate complied in form with s. 36 and s. 67 of the Schedule.
I also note that this issue specifically asks me to address whether the applicant is precluded from proceeding with a claim for an IRB because he did not apply for the benefit within 104 weeks of the accident. I do not see a requirement in the Schedule which specifically dictates that, in order to collect an IRB, an insured person must apply for an IRB within 104 weeks of the accident. The Schedule only dictates that the claimant suffers a substantial inability to perform the essential tasks of that employment within 104 weeks. This is different than applying for a benefit.
To further clarify, perhaps this issue could have been phrased whether the applicant is precluded from proceeding with a claim for an IRB because he did not qualify for the benefit within 104 weeks of the accident. Apply and qualify are two very different concepts. In other words, the focus should always be on the eligibility test in the Schedule which I discuss below (and not only on applying within 104 weeks).
Given my reasons above, it is unnecessary for me to consider the applicant’s alternate argument with respect to non-compliance with s. 36 of the Schedule in relation to relief from forfeiture.
SUBSTANTIVE ISSUE:
Is the applicant entitled to receive a weekly income replacement benefit in the amount of $400.00 per week for the period December 17, 2013, to date and ongoing?
CLAIM TO INCOME REPLACEMENT BENEFITS
- Notwithstanding, that I have found that the applicant provided the First Disability Certificate, he must still satisfy the eligibility criteria set out in s. 5 and s. 6 of the Schedule.
LAW AND ANALYSIS
As a starting point, I point out that the applicant argues that the respondent did not send the applicant for an examination or assessment with respect to his entitlement for an income replacement benefit. I do not see a requirement in the Schedule that the insurer must send an insured to an assessment. It is clear law, that the respondent is not required to disprove entitlement. The burden rests on the applicant to prove on a balance of probabilities that he is entitled to an income replacement benefit. With this in mind, I now turn to the application of the legal test to the facts of this case.
Eligibility for income replacement benefits for the first 104 weeks post-accident is found in s. 5(1) of the Schedule. To be eligible for income replacement benefit an insured person must as a result of and within 104 weeks after the accident, suffer a substantial inability to perform the essential tasks of that employment.
If the criteria are met, income replacement benefits are to be provided for the period outlined in section 6 below:
(1) Subject to subsection (2), an income replacement benefit is payable during the period that the insured person suffers a substantial inability to perform the essential tasks of the employment in respect of which he or she qualifies for the benefit under section 5. (Emphasis added)
(2) The insurer is not required to pay an income replacement benefit,
a) For the first week of the disability;
b) For any period longer than 104 weeks of disability, unless, as a result of the accident, the insured person is suffering a complete inability to engage in any employment for which he or she is reasonably suited by education, training or experience. (Emphasis added)
Respondent’s Position
- The respondent advanced several reasons why the applicant is not entitled to an income replacement benefit. They are:
i. the applicant did not submit a disability certificate confirming entitlement to IRB’s until February 16, 2017 (this was 3.5 years post the accident) and therefore he did not meet the disability test;
ii. in order to qualify for a post-140 week IRB’s an insured person must establish eligibility to IRB’s within the first 104 weeks following the accident which he did not do;
iii. there was no adequate proof that the accident caused the applicant his inability to work and the applicant had significant pre-accident health history that contributed to his apparent inability to perform the essential tasks of his employment; and
iv. the applicant has failed to demonstrate quantum and if income benefits cannot be calculated they cannot be paid.
Applicant’s Position
- As I understand, the position of the applicant is as follows:
i. there is significant medical evidence supporting the applicant’s claim for an income replacement benefit;
ii. on February 13, 2017, Dr. MC completed an updated Disability Certificate indicating that DW is substantially unable to perform the essential task of his employment within 104 weeks of the accident and also that and that he suffers a complete in ability to carry on a normal life.
The establishment of eligibility to IRB within the first 104 weeks is critical to this casen as the Ontario Court of Appeal in State Farm v. Wadhwani7 has held that that to qualify for income replacement benefits under s. 5 of the Schedule beyond a period of 104 weeks (as the applicant has requested), an insured must establish eligibility for the benefits within the first 104 weeks after the accident under s. 4(1) of the Schedule.
What is clear from the Court of Appeal’s decision is that if the applicant did not obtain a determination of entitlement at any time during the first 104 weeks after the accident, he or she will be precluded from seeking IRBs after 104 weeks despite a deteriorating condition.
Has the applicant established eligibility to IRB within the first 104 weeks of the accident?
As stated above, eligibility for income replacement benefits for the first 104 weeks post-accident an insured person must as a result of and within 104 weeks after the accident, suffer a substantial inability to perform the essential tasks of that employment.
In his Application for Accident Benefits Form (OCF-1), the applicant indicated that he was self-employed as a subcontractor roofer and working at the time of the accident. On the Application under the “Income Replacement Determination” section, the applicant indicated that he worked 40+ hours per week, his gross income was approximately $20,000.00 and that the injuries prevented him from working as of September 17, 2013. I questioned how on October 24, 2013, when DW signed the Application (OCF-1) he could complete the form indicating that his injuries prevent him from working as of September 17, 2013, when in his Affidavit at paragraph 15 he deposes that: “Following the accident, I was off work for approximately one week.”
As discussed prior, Dr. C. completed the First Disability Certificate and answered “N/A”, indicating that either DW did not meet the test for this benefit or this section was not applicable. In any event, the First Disability Certificate clearly did not support DW’s claim for IRB. No Affidavit from Dr. C. or other direct evidence on this point was provided to explain if DW was making a claim for IRB’s why this section of the certificate was marked “N/A”. I queried why another disability certificate was not obtained sometime after October 23, 2013, and certainly prior to September 16, 2015 (within 104 weeks of the accident) to preserve the insured’s right to IRBs in the future.
Notably, the Updated Disability Certificate was dated February 13, 2017 (3 years and 5 months post-accident which was not within 104 week of the accident).
Dr. M. completed a Minor Injury Treatment Discharge Report (OCF-24) dated January 6, 20148 which indicated that DW was employed at the time of the accident and was able to do his pre accident work activities. The doctor checked off box: “Full pre-accident” and also wrote: “Progressing well at this point.” There was no mention whatsoever that DW suffered a substantial inability to perform the essential tasks of his employment.
The psychological report of AM and SS9 dated March 23, 2017 opines that DW has not been able to work in any capacity since January 2015. However, it does not directly link DW’s impairments to the accident. This report was not provided within 104 weeks of the accident. The law requires that insured must establish eligibility for the benefits within the first 104 weeks after the accident.
The Physiatry Medical Legal Assessment of Dr. SB, dated March 24, 2017, opines that it is reasonable to conclude that the mild worsening of the supraspinatus tears and potential labral tears were attributed to the accident and materially contributed to the progressive left-sided adhesive capsulitis. In the same report, Dr. SB also states that “it is difficult to say with certainty that the accident contributed to the left shoulder symptoms” and that “Mr. W. was somewhat vague in articulating when the frozen shoulder developed.” Again, this report was not produced within 104 weeks of the accident so it cannot be used by the applicant to establish eligibility for the benefits within the first 104 weeks after the accident.
There was no Employer’s Confirmation of Income (OCF-2) that was provided by the applicant at any time. The applicant’s explanation was that he requested it but one was never provided by Chislett Roofing. Again, the applicant has the onus to prove his case and this includes providing key documents such as an OCF-2 to support entitlement to the benefit.
It appears that the first MRI of DW’s shoulder was not done until October 1, 2016. Although it showed several tears in his shoulder, it was not clear to me from the evidence provided how these injuries were linked to the accident, or if they happened prior to the accident or after. Again, the timing of this MRI is also problematic for the applicant as it was obtained nearly 3 years after the accident and he did not have the benefit of the MRI results during the initial 104 weeks when it was incumbent upon him to establish eligibility to the benefit as required by the Schedule and the case law.
In the case before me, there were no medical reports produced within 104 weeks of the accident to positively answer the specific question of whether DW was substantially unable to perform the essential tasks of employment. One of the most key pieces of medical evidence as far as entitlement to IRB is the OCF-3. Unfortunately, that one that was produced (the First Disability Certificate) did not did not support DW’s claim for an IRB.
Also, on the First Disability Certificate, to the question: “Can the applicant return to work on modified hours and/or duties?” the doctor answered “Yes” and noted that the applicant has a “pre-existing bilateral rotary cuff injuries/tear”. This medical information was indicative of someone who was able to substantially to perform the essential tasks of his employment. Certainty, the fact that the insured returns to work is not affirmative evidence that the insured does not meet that test. However, what is required is medical evidence to show that the insured suffers a substantial inability to perform essential tasks of his or her job.
The second certificate that was produced (the Updated Disability Certificate) did support a claim for an IRB was dated February 13, 2017. However, it was not produced within the 104 weeks of the accident so it cannot be used now to say that the applicant was able to establish eligibility to the benefit within 104 weeks. That determination must have been made at any time during the first 104 weeks after the accident and not after. Looked another way, if the applicant was allowed to succeed it would extend an insured’s entitlement to IRBs for an indeterminate period of time and effectively undermine the statutory principle of finality embraced by the Court of Appeal in Wadhwani.
In my view, based on the totality of the evidence, the applicant has not provided sufficient medical evidence to demonstrate that he was substantially unable to perform the essential tasks of his employment during the first 104 weeks of the accident. Also, as he has not obtained entitlement during this initial period, he is precluded from seeking IRBs after 104 weeks.
CONCLUSION AND ORDER
- Having reviewed all of the evidence and the submissions of the parties, for the foregoing reasons, it is ordered that:
i. the applicant’s appeal for an income replacement benefit is dismissed; and
ii. as a result of this conclusion, the applicant is not entitled to interest.
Released: June 27, 2017
Cezary Paluch
Adjudicator
Footnotes
- I noted that DW’s Affidavit (paragraph 42) and the main submissions refer to December 11, 2013 (paragraph 33) as being the date the document was faxed to the insurer but the fax confirmation page and the applicant’s reply submission refer to the December 17, 2013 (paragraph 2 and 7) and the inconsistency between the two dates appear to be minor typos.
- Applicant’s Document Brief at Tab P.
- Applicant’s Document Brief at Tab Q.
- Applicant’s Document Brief at Tab C.
- Applicant’s Document Brief at Tab C.
- This includes a disability certificate under section 21, 36 or 37.
- 2013 ONCA 662.
- Respondent’s Document Brief at Tab E.
- Respondent’s Document Brief at Tab L.

