Licence Appeal Tribunal File Number: 23-015766/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:
Sumaiyabanu Lala
Applicant
and
TD General Insurance Company
Respondent
PRELIMINARY ISSUE HEARING DECISION AND ORDER
ADJUDICATOR:
Kate Grieves
APPEARANCES:
For the Applicant:
Muhammad Aftab Alam, Counsel
For the Respondent:
Robert Bowman, Counsel
HEARD:
By Way of Written Submissions
OVERVIEW
1Sumaiyabanu Lala (“the applicant”) was involved in an accident on July 3, 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 TD General Insurance Company (“the respondent”) and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (“the Tribunal”) for resolution of the dispute.
PRELIMINARY ISSUE IN DISPUTE
2The preliminary issue to be decided is:
i. Is the applicant barred from proceeding to a hearing for all of the benefits claimed in her application because she failed to dispute their denial within the 2-year limitation period?
RESULT
3The applicant is statute barred from proceeding with her application pursuant to section 56 of the Schedule.
ANALYSIS
4The respondent submits that there was a clear and unequivocal denial of the benefits in dispute on March 30, 2021, triggering the limitation period, and the applicant did not appeal the denial within two years.
5The applicant submits that the denial letter was defective, and therefore the limitation period was not triggered. The applicant makes no suggestion that she was not aware of the limitation period or that it was running. There is no explanation provided in her submissions as to why she failed to commence her application until December 29, 2023.
6Much of the applicant’s submissions do not address whether she complied with her obligation under section 56 of the Schedule. The applicant’s submissions regarding the sufficiency of the denials focus on challenging the respondent’s reasons for denying the benefits, rather than on the sufficiency of those reasons. Her submissions are largely about alleged errors in the conclusions drawn by the insurer’s examinations or failure to consider additional medical evidence.
Law
7The limitation period for accident benefits claims is set out in section 56 of the Schedule. It states that applications to dispute the denial of a benefit shall be commenced within two years after the insurer’s refusal to pay the benefit.
8In order for section 56 to be triggered, the respondent must have provided a valid notice of denial in accordance with the principles set out in Smith v. Co-operators General Insurance Company, 2002 SCC 30 (“Smith”). According to Smith, the refusal to pay the benefit must contain straightforward and clear language, it must be directed towards an unsophisticated person, it must outline the dispute resolution process and the relevant time limits that govern the process, and it must provide valid or other reasons for the denial.
9Further, pursuant to T.F. v. Peel Mutual Insurance Company, 2018 CanLII 39373 (ON LAT) (“T.F.”) and Hedley v. Aviva Insurance Company of Canada, 2019 ONSC 5318 (“Hedley”), the notice must provide a valid medical and any other reason for the denial.
10An insurer has a continued obligation to adjust an accident benefits claim, even after a denial of a benefit, but that obligation does not mean that a refusal can only take place once that process is complete, nor does it give rise to a new limitation period. Even if the insurer gives legally incorrect reasons for denying a benefit, a clear and unequivocal denial notice provided by the insurer is sufficient to trigger a limitation period. (See: Sietzema v. Economical Mutual Insurance Company, 2014 ONCA 111).
The respondent’s denial notice was compliant with the Schedule
11I find that the letter dated March 30, 2021 is a valid denial, triggering the limitation period. It provides valid reasons for the denial on the basis of the assessors’ conclusions from a physical and psychological perspective, and that she did not suffer a substantial inability to perform the essential tasks of her pre-accident employment. It is written in straightforward and clear language and indicates that her benefits would be stopped effective April 13, 2021.
12The letter is sufficiently clear, provided valid reasons for the denial, outlined the dispute resolution process, and the two-year time limit to dispute the decision. I find that the limitation period for therefore was triggered on March 30, 2021 by a valid denial.
The application was not filed within the limitation period
13The application to the Tribunal was filed on December 29, 2023. Therefore, the applicant did not file her application for the benefits in dispute within the limitation period. The limitation period elapsed 260 days prior to the submission of the application.
14Pursuant to section 7 the Licence Appeal Tribunal Act, 1999 the Tribunal has statutory discretion to extend the two-year limitation period based on four factors: a bona fide intention to appeal within the limitation period; the length of the delay; prejudice to the other party; and the merits of the appeal (see: Fratarcangeli v. North Blenheim Mutual Insurance Company, 2021 ONSC 3997; Manuel v. Registrar, Motor Vehicle Dealers Act, 2002, 2012 ONSC 1492. In the absence of any submissions, the applicant has not discharged her onus to establish why I should exercise my discretion to extend the limitation period. I have no basis to find that any of the factors weigh in her favour in order to extend the limitation period. Therefore, I decline to do so.
ORDER
15The applicant is statute barred from proceeding with her application pursuant to section 56 as it was commenced more than two years after a valid denial from the respondent.
16The application is dismissed.
17The Tribunal shall vacate any date that has been scheduled for a substantive issue hearing. The Tribunal file will be closed.
Released: August 7, 2024
___________________________
Kate Grieves
Adjudicator