Jin v. Certas Home and Auto Insurance Company, 2023 CanLII 13061

Citation: Jin v. Certas Home and Auto Insurance Company, 2023 ONLAT 20-011392/AABS

Licence Appeal Tribunal File Number: 20-011392/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:

Wen Hua Jin

Applicant

and

Certas Home and Auto Insurance Company

Respondent

DECISION

VICE-CHAIR: Brett Todd

APPEARANCES:

For the Applicant: Yu Jiang, Paralegal

For the Respondent: Yann F. Grand-Clement, Counsel

HEARD BY WAY OF WRITTEN SUBMISSIONS

BACKGROUND

1Wen Hua Jin (the “applicant”) was involved in an automobile accident on January 16, 2019 and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”).

2Certas Home and Auto Insurance Company (the “respondent”) characterized the applicant’s injuries as a “minor injury” as defined in s. 3 of the Schedule, subjected her to the Minor Injury Guideline (the “MIG”) and its $3,500.00 funding limit on treatment, and denied certain medical benefits. The applicant submitted an application to the Licence Appeal Tribunal – Automobile Accident Benefits Service (the “Tribunal”).

3Following an insurer’s examination (“IE”) of the applicant, the respondent removed the applicant from the MIG in September 2021 and approved the treatment plans/OCF-18s and interest in dispute. As a result, the applicant withdrew these issues, which had been identified in a Tribunal Case Conference Report and Order dated August 26, 2021 that set down the disputed items to be heard in a written hearing scheduled for March 31, 2022.

4This leaves in dispute the request for an award, as the applicant claims that the insurer unreasonably withheld and delayed payments with regard to the MIG and the three treatment plans originally in dispute.

ISSUES IN DISPUTE

5The following issue is in dispute:

1. Is the respondent liable to pay an award pursuant to s. 10 of Regulation 664 because it unreasonably withheld or delayed payments to the applicant, plus interest?

RESULT

6I find that:

i. The respondent is ordered to pay an award under s. 10 of Regulation 664 in the amount of 30 per cent of the value of the three treatment plans that were originally in dispute, plus interest. As the value of these treatment plans is $10,372.28, the award is for $3,457.43, plus interest as specified under Regulation 664.

ANALYSIS

7I agree with the applicant and find that the respondent unreasonably withheld and delayed payment of the three treatment plans that were originally in dispute. The respondent did not respond to medical evidence produced by the applicant in a responsible or timely fashion. I primarily fault the insurer for maintaining the applicant’s status within the MIG well beyond the point where further medical investigation was clearly warranted to properly and efficiently assess her claims to having sustained injuries beyond that defined as minor in the Schedule.

8Section 10 of Regulation 664 permits the Tribunal to award a lump sum of up to 50 per cent of the amount that the applicant