Mehmood v. Co-operators General Insurance Company, 2023 CanLII 42605

Licence Appeal Tribunal

Citation: Mehmood v. Co-operators General Insurance Company, 2023 ONLAT 21-013638/AABS - PI

Licence Appeal Tribunal File Number: 21-013638/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:

Tariq Mehmood

Applicant

and

Co-operators General Insurance Company

Respondent

PRELIMINARY ISSUE DECISION AND ORDER

ADJUDICATOR:

Tavlin Kaur

APPEARANCES:

For the Applicant:

Tariq Mehmood, Applicant

For the Respondent:

Emily Schatzker, Counsel

HEARD:

By Way of Written Submissions

REASONS FOR DECISION AND ORDER

OVERVIEW

1Tariq Mehmood, the applicant, was involved in an automobile accident on September 9, 2019, and sought benefits pursuant to the Statutory Accident Benefits Schedule – Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”). The applicant was denied benefits by the respondent, Co-operators General Insurance Company (“Co-operators”), and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.

PRELIMINARY ISSUE

2The preliminary issue to be decided is whether the applicant is barred from proceeding to a hearing for the income replacement benefit because the applicant failed to submit an OCF-3 in the time period prescribed under Section 55(1)1. of the Schedule?

RESULT

3I find that the applicant failed to submit a completed Disability Certificate (“OCF-3”) within the timelines prescribed by the Schedule and is therefore not entitled to the income replacement benefit.

ANALYSIS

Background

4On October 8, 2019, the respondent sent the applicant the Application for Accident Benefits Package, with blank forms including the Application for Accident Benefits (“OCF-1”), Employer’s Confirmation Form (“OCF-2”), and Disability Certificate (“OCF-3”). On October 21, 2019, the applicant submitted the OCF-1 and the Election of Income Replacement, Non-Earner or Caregiver Benefit Form (“OCF-10”). The applicant elected to receive the income replacement benefit. On November 9, 2019, the respondent denied the income replacement benefit on the basis that the applicant had returned to work.

5The respondent submits that the applicant did not submit an OCF-3 with his application package or any time thereafter. It is the respondent’s position that the applicant was required to submit an OCF-3 to establish entitlement to income replacement benefit within 104 weeks of the accident by September 9, 2021. He has never done so and thus, cannot be entitled to income replacement benefits.

6The applicant did not provide any submissions or evidence.

Legislation

7Section 32(5) requires that an applicant submit a completed and signed application for benefits to the insurer within 30 days after receiving the application forms. Section 36(2) of the Schedule specifies that “an applicant for a specified benefit shall submit a completed disability certificate with his or her application under section 32.” Therefore, the correct limitation period to submit the OCF-3 along with the OCF-1 remains 30 days after receiving the application forms from the respondent, as provided by section 32.

8In order for an OCF-3 to be considered complete, it must be filled out and signed by a health practitioner of the applicant's choice. Once the insurer receives that completed OCF-3, it has 10 business days to either pay the benefit, ask for a section 44 assessment or a request for more information under section 33.

9Section 36(3) states “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”.

10Section 55(1) provides that the applicant shall not apply to the Tribunal if he “has not notified the insurer of the circumstances giving rise to a claim for a benefit or has not submitted an application for the benefit within the times prescribed by (the Schedule).”

11Based on the evidence before me, it appears that the applicant did not submit his OCF-3 to the respondent. The applicant did not provide any submissions or evidence to refute this fact. While section 34 of the Schedule allows an extension of a deadline if there is a reasonable explanation for the delay, the applicant has not offered one.

12Therefore, I find that the applicant has failed to do so and according to the Schedule, the respondent is not liable to pay for the income replacement benefit for any period before a completed OCF-3 is submitted. Therefore, the applicant cannot apply to the Tribunal to dispute the income replacement benefit because he failed to comply with the timelines prescribed by the Schedule. The application is dismissed.