Licence Appeal Tribunal File Number: 23-005075/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:
Jonas Georges
Applicant
and
Wawanesa Mutual Insurance Company
Respondent
PRELIMINARY ISSUE HEARING DECISION AND ORDER
ADJUDICATOR: Ulana Pahuta
APPEARANCES:
For the Applicant: Pasquale Maiolo, Paralegal
For the Respondent: Nicholas Mester, Counsel
HEARD: By way of written submissions
OVERVIEW
1Jonas Georges, the applicant, was involved in a motor vehicle accident on January 20, 2017 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 certain benefits by the respondent, Wawanesa Mutual Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (“Tribunal”) for resolution of the dispute.
PRELIMINARY ISSUE IN DISPUTE
2The preliminary issue to be decided is:
a) Is the applicant barred from proceeding to a hearing for all of the benefits claimed in his application because the applicant failed to dispute their denial within the 2-year limitation period?
RESULT
3The applicant is barred from proceeding with his application.
ANALYSIS
Background
4The applicant was involved in a motor vehicle accident, and applied to the respondent for income replacement benefits (“IRBs”). By way of letter dated June 12, 2017, the respondent notified the applicant that it had determined that the applicant was no longer eligible for IRBs. The correspondence included the multidisciplinary s. 44 assessments, summarized the assessors’ findings and advised the applicant that he had two years from the date of the denial to dispute the respondent’s decision.
5The applicant filed his Tribunal application on May 3, 2023.
Parties’ Positions
6The respondent submits that the applicant failed to bring his application within the two-year limitation period stipulated in s. 56 of the Schedule. It argues that it provided a clear and unequivocal denial of the IRB claim in its June 12, 2017 correspondence, and that the applicant failed to dispute the denial until almost five years later. The respondent contends that s. 56 of the Schedule is clear that as the applicant did not dispute the denial within the two-year limitation period, he is statute barred from pursuing his IRB claim.
7The applicant did not file any submissions or evidence in support of his case.
Law
8Section 56 of the Schedule provides that an application to dispute a denial of a benefit shall be commenced within two years of the insurer’s refusal to pay.
9Section 7 of the Licence Appeal Tribunal Act, 1999 (“LAT Act”) allows the Tribunal to extend a limitation period. In considering whether to exercise its discretion to extend the limitation period, the Tribunal must consider the following four factors set out in Manuel v. Registrar, 2012 ONSC 1492, to determine if the justice of the case requires the extension:
a) A bona fide intention to appeal within the limitation period;
b) The length of delay;
c) Prejudice to the other party; and
d) Merits of the appeal.
10The onus is on the applicant to establish reasonable grounds for an extension under section 7 of the LAT Act.
The respondent’s denial notice was valid
11Upon review of the June 12, 2017 correspondence, I find that the respondent provided a valid denial of the applicant’s IRB claim. The respondent provided a medical reason for the denial, properly identified the benefit in dispute, and provided the applicant with information on how to dispute the decision. The reasons were clear and sufficient to allow an unsophisticated person to make an informed decision to either accept or dispute the decision at issue. I find that this was a clear and unequivocal denial in accordance with the principles set out in Smith v. Co-operators General Insurance Co, 2002 SCC 30.
12Having determined that respondent’s denial was valid and that the applicant failed to bring his application within the two-year limitation period stipulated in s. 56, I must still consider whether an extension of the limitation period should be granted pursuant to s. 7 of the LAT Act.
Section 7 of the LAT Act
13The applicant did not request an extension of the limitation period and as a result, has not met his onus to establish reasonable grounds for an extension under section 7 of the LAT Act. I decline to exercise my discretion to extend the limitation period.
CONCLUSION AND ORDER
14I find that the applicant is statute-barred from proceeding with his application pursuant to s. 56 of the Schedule.
15The application is dismissed and the substantive hearing is vacated.
Released: January 31, 2024
Ulana Pahuta
Adjudicator