A. A. v. State Farm Mutual Automobile Insurance Company, 2017 CanLII 69282

Licence Appeal Tribunal

Date: 2017-04-11

Tribunal File Number: 16-000449/AABS

Case Name: 16-000449 v State Farm Mutual Automobile Insurance Company

In the matter of an Application for Dispute Resolution pursuant to subsection 280(2) of the Insurance Act, RSO 1990, c I.8., in relation to statutory accident benefits.

Between:

A. A.

Applicant

and

State Farm Mutual Automobile Insurance Company

Respondent

DECISION

ADJUDICATOR: Chris Sewrattan

APPEARANCES:

For the Applicant: A. A., self-represented

For the Respondent: Darrell March, counsel for the Respondent

HEARD: Written Hearing 4: January 19, 2017

Overview:

1The applicant was injured in a motor vehicle accident on October 25, 2011. He applied for accident benefits under the Statutory Accident Benefits Schedule – Effective September 1, 2010 (the “Schedule”). State Farm denied payment for a number of benefits.

2State Farm Mutual Automobile Insurance Company (“State Farm”) has brought a preliminary issue motion to dismiss the applicant’s claim for Non-Earner Benefits on the ground that it was commenced after the expiry of the two-year limitation period set out in the Schedule. State Farm also seeks costs against the applicant.

Preliminary Issue:

3Is the applicant precluded from proceeding with his claim for non-earner benefits because he failed to apply to the Tribunal within two-years of the date of the denial?

Result:

4As a result of s. 56 of the Schedule, the applicant is precluded from proceeding with this claim for non-earner benefits in relation to the October 25, 2011 accident. His claim was brought outside of the two-year limitation period.

5State Farm’s claim for costs is denied.

Discussion:

Facts

6The timeline of the communications between the parties when dealing with the claim is important to resolve the preliminary issue, which concerns a limitation period.

7The applicant was injured in a motor vehicle accident on October 25, 2011.¹

8State Farm sent the applicant a letter dated November, 2011 with material relating to the accident. Among this material was an application for accident benefits.

9The applicant submitted an application for accident benefits dated November 24, 2011 to State Farm. In the application, the applicant identified himself as self-employed.

10By letter dated November 25, 2011, State Farm advised the applicant that he was not eligible for a non-earner benefit because he was employed at the time of the accident. This document, an Explanation of Benefits, and its content is critical to resolving the limitation period issue.

11A Disability Certificate dated January 7, 2012 was forwarded to State Farm. The certificate stated that the applicant was substantially unable to perform the essential tasks of his pre-accident employment.

12More than four years after the accident, on February 4, 2016, the applicant submitted to State Farm a form in which the applicant advised that he elects to receive a non-earner benefit.

13By letter dated February 17, 2016, State Farm again denied the applicant’s claim for a non-earner benefit. In the letter, State Farm advised the applicant that he had been denied a non-earner benefit on November 25, 2011 and he was outside the two-year limitation period in which to dispute that denial.

14On June 3, 2016 the applicant disputed State Farm’s denial of his claim to a non-earner benefit. He filed an Application by an Injured Person for Auto Insurance Dispute Resolution Under the Insurance Act with the Licence Appeal Tribunal.

Analysis

15Section 56(1) of the Schedule sets out a limitation period of two years in which an applicant may bring a claim for dispute resolution. The two year limitation period begins when the insurer notifies the applicant of its refusal to pay the benefit.

16The applicant’s submissions do not squarely address the test set out in s. 56(1). Rather, they address sections 32 and 34 of the Schedule. The applicant submits, essentially, that he could not have elected for non-earner benefits earlier because he did not realize that he was in need of the benefit until he read a report by an Independent Medical Examiner. The report is dated January 21, 2016, and the applicant read it in February 2016. In the applicant’s view, this triggered the circumstances that gave rise to his entitlement to the benefit. He filed his application to the Tribunal within two years of February 2016, putting him well within the limitation period set out in s. 56(1) of the Schedule.

17I am unpersuaded by the applicant’s submission for the following reasons. The law is clear that the limitation period begins to run when an insurer notifies the applicant of its refusal to pay the benefit. The limitation period under s. 56(1) of the Schedule is unconcerned with when the circumstances which gave rise to the applicant’s entitlement to a benefit materialized.

18Looking squarely at the test set out in s. 56(1), State Farm advised the applicant that it was refusing to pay for a non-earner benefit in the Explanation of Benefits dated November 25, 2011. The applicant had two-years in which to dispute this denial of payment. The limitation period expired in November 2013. The applicant’s appeal of this denial is well outside the limitation period, June 3, 2016.

19State Farm’s Explanation of Benefits dated November 25, 2011 is clear and unequivocal in its refusal of the non-earner benefit. The refusal complies with the requirements required by the law (see Smith v. Co-operators General Insurance Co., [2002] 2 S.C.R. 129, 2002 SCC 30 at para 14 (cited to SCC).

20The applicant’s claim for a non-earner benefit in relation to the October 25, 2011 accident is outside the two-year limitation period mandated by s. 56(1) of the Schedule.

Costs

21State Farm claims for the cost of this hearing. Costs are awarded under Rule 19.1 of the LAT Rules where a party in a proceeding has acted unreasonably, frivolously, vexatiously, or in bad faith.

22After reading the applicant’s submissions, I find that he genuinely believes that his claim is properly before the Tribunal. His conduct does not rise to any of the impugned levels of conduct enumerated in Rule 19.1.

Conclusion:

23As a result of s. 56 of the Schedule, the applicant is precluded from proceeding with this claim for non-earner benefits in relation to the October 25, 2011 accident.

24State Farm is not entitled to costs under Rule 19.1.

25The parties are ordered to attend the telephone case conference scheduled for May 12, 2017 at 2 p.m.

Footnotes

1. 1The applicant claims in his affidavit that the accident occurred on October 15, 2011 and State Farm erroneously diarized the date as October 25, 2011. The applicant’s Application by an Injured Person for Auto Insurance Dispute Resolution Under the Insurance Act to the Licence Appeal Tribunal identifies the accident date as October 25, 2011. The discrepancy, while important to the applicant, is not relevant to the issue in dispute.