Licence Appeal Tribunal File Number: 25-001641/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:
Baffour Amankwatia
Applicant
and
TTC Insurance Company Limited
Respondent
PRELIMINARY ISSUE HEARING DECISION AND ORDER
ADJUDICATOR:
Brian Norris
APPEARANCES:
For the Applicant:
Sulakshana Genthirakumar, Paralegal
For the Respondent:
Nabil Mahmood, Counsel
Heard:
By Way of Written Submissions
OVERVIEW
1Baffour Amankwatia (“the Applicant”) was involved in an automobile accident on December 23, 2023 and sought benefits from TTC Insurance Company Limited (“the Respondent”) pursuant to the Statutory Accident Benefits Schedule – Effective September 1, 2010 (including amendments effective June 1, 2016) (“the Schedule”).
2The Applicant was denied benefits by the Respondent and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (“the Tribunal”) for resolution of the dispute.
PRELIMINARY ISSUE IN DISPUTE
3The preliminary issue to be decided is:
i. Is the Applicant barred from proceeding with his claim for benefits as he failed to submit the application for benefits (OCF-1) within the time prescribed by the Schedule, and failed to provide a reasonable explanation for the delay?
RESULT
4The Applicant is permitted to proceed with his application.
PRELIMINARY ISSUE
5I acknowledge the Respondent’s submissions that the Applicant exchanged his documents four days after the deadline to exchange documents, as ordered by the Tribunal. To the Respondent, the documents should be disregarded entirely due to the delayed exchange. It submits that such a delay is fatal to the Applicant’s overall argument.
6I dismiss the Respondent’s request to exclude the documents. This is because the Respondent has failed to identify any prejudice suffered as a result of the Applicant’s late filing. It was provided an opportunity to tender submissions and evidence, which it did, and then to tender reply submissions and evidence, which it did. I find no evidence to suggest that the late filing prejudiced the Respondent in advancing the preliminary issue and replying to the Applicant’s response.
BACKGROUND
7The Applicant was involved in an accident on December 23, 2023 when the bus he was riding on collided with another bus at a transit station. The Applicant called TTC customer service following the accident and was given the contact information for the claims department. Then, he called the claims department and, according to the transcript from an examination under oath (“EuO”) on January 24, 2025, was given a claim number in relation to his accident.
8The Applicant retained counsel to initiate a claim for accident benefits. Counsel for the Applicant submitted an application for accident benefits on January 31, 2024. However, the application was faxed to the incorrect fax number and was never received by the Respondent.
9On February 22, 2024, the Applicant submitted a treatment confirmation form through his healthcare provider. In response, on March 8, 2024, the Respondent wrote to the Applicant and advised that it never received the application for accident benefits and that it could not process the treatment confirmation form without it.
10On July 22, 2024, the Applicant submitted a disability certificate to the Respondent. In response, on July 31, 2024, the Respondent wrote to the Applicant and reiterated that it required an application for accident benefits before responding to the disability certificate.
11The Applicant’s healthcare provider sent a copy of the accident benefits application to the Respondent on August 19, 2024, via email.
12On August 28, 2024, the Respondent denied the Applicant’s claim for benefits due to the delayed submission of the application for accident benefits. In a letter dated August 28, 2024, the Respondent asked the Applicant to provide a reasonable explanation for the delayed submission.
13On November 20, 2024, counsel for the Applicant emailed the Respondent to advise that the delayed submission of the application for accident benefits was due to it being faxed to the incorrect number and that the intention was to submit it on January 31, 2024.
14To-date, the Respondent maintains that the Applicant is statute-barred from obtaining accident benefits because he failed to submit an application for accident benefits within the prescribed timeframe and because he has no credible explanation for the delayed submission.
15The Applicant contends that he has a credible explanation in that he believed he submitted the application for accident benefits through his counsel, but they inadvertently delivered it to the wrong address.
ANALYSIS
16Section 32(1) of the Schedule requires an insured person to inform an insurer of their intention to claim accident benefits within seven days of the accident, or as soon as practicable after.
17Pursuant to section 32(5) the Applicant is required to submit a completed and signed application for benefits to the insurer within 30 days after receiving the application forms.
18Section 34 of the Schedule states that if the insured person does not comply with that time limit, the insured person may still be entitled to benefits if they have a reasonable explanation for the delay.
19The interpretation of “reasonable explanation” is guided by Horvath and Allstate Insurance Company of Canada, FSCO A02-000482, June 9, 2003, and was reiterated in K.H. v. Northbridge, 2019 CanLII 101613 (ON LAT). The guiding principles are summarized as follows:
An explanation must be determined to be credible or worthy of belief before its reasonableness can be assessed.
The onus is on the insured person to establish a “reasonable explanation”.
Ignorance of the law alone is not a “reasonable explanation”.
The test for “reasonable explanation” is both a subjective and objective test that should take account of both personal characteristics and a “reasonable person” standard.
The lack of prejudice to the insurer does not make an explanation automatically reasonable.
An assessment of reasonableness includes a balancing of prejudice to the insurer, hardship to the claimant and whether it is equitable to relieve against the consequences of the failure to comply with the time limit.
20Additionally, pursuant to Hussein v. Intact Insurance Company, 2025 ONSC 842 (“Hussein”), an interpretation of section 32(1) must recognize the reality that consumers who have motor vehicle accidents are in a vulnerable position, particularly in the period immediately following the accident. Hussein provides the Respondent with a positive obligation to assist an insured person with their application for accident benefits and affirms that insurers cannot simply rely on the insured person’s inaction to determine that no benefits will be claimed.
21Pursuant to section 55(1)1, an insured person may not apply to the Tribunal if they have not notified the insurer of the circumstances giving rise to a benefit or has not submitted an application for the benefit within the times set out in the Schedule.
22Neither party disputes that the Applicant failed to notify the Respondent of the accident within the timelines prescribed by the Schedule. Instead, the Respondent submits that the Applicant failed to deliver the OCF-1 within 30 days, as prescribed by section 32(5) of the Schedule without a reasonable explanation.
23I find that the Respondent failed to comply with its obligation to provide information to assist the Applicant in applying for benefits, as outlined in section 32(2) of the Schedule. Accordingly, the Applicant’s obligation to apply for accident benefits within 30 days does not apply and he is not statute-barred from proceeding with his application.
24The Applicant submits that he is relatively unsophisticated with regards to accident benefits and that English is his second language. He highlights that the initial correspondence between he and the Respondent occurred in writing and that he believed the Respondent would contact his counsel, whom he retained about a month following the accident. To the Applicant, the issue regarding the submission of his application for accident benefits being sent to the incorrect fax number, as well as the fact that the Respondent was unaware he retained counsel, could have been avoided had the Respondent called him on the telephone to discuss the issue instead of writing to him about it.
25The Respondent rejects the Applicant’s position and submits that he is bound by the actions, or in this case inaction, of his counsel and that mere reliance on a legal representative is not a reasonable explanation. The Respondent maintains that the Applicant did nothing following the occasions that it notified him that his application for accident benefits was not delivered and that the document is required to process his claims. The Respondent submits that it faces real and substantial prejudice due to the non-compliance because it had no legal basis to issue requests for information pursuant to section 33 of the Schedule, or to seek an examination pursuant to section 44.
26I find that the Respondent has not complied with its obligation to provide information to assist the Applicant in applying for benefits. I acknowledge that the Respondent provided the Applicant with the accident benefits package and followed-up with written requests when the completed application was never received. However, it made no other effort to contact the Applicant after the accident benefits package was delivered to him and never returned. Moreover, the Applicant proceeded with his claim for benefits when he engaged in clinical treatment with a registered healthcare provider and submitted a treatment confirmation form and disability certificate to the Respondent. This is a clear indication by the Applicant of a desire to claim benefits and it was incumbent upon the Respondent to contact the Applicant and clarify his intentions.
27The Respondent ought to have contacted the Applicant in a different fashion once the accident benefit package was delivered, and no response was received but for the submission of treatment plans. As noted, the Applicant is unsophisticated with respect to accident benefits and the claims process. He retained counsel and relied on them to initiate and manage his claim but his counsel send the application to the incorrect insurer. It was reasonable for him to not reply to those letters on the genuine belief that his counsel was receiving the notices and would respond on his behalf. I agree with the Applicant that, had the Respondent contacted him via telephone upon receipt of the treatment plans despite not having received the returned application for benefits, he would have told them that he retained counsel, and the Respondent could work out the issue with them directly. Unfortunately, the Respondent never called the Applicant, and he never had the opportunity to advise it that he retained counsel.
28The Respondent relied on the Applicant’s inaction instead of contacting him to assist with his claim for benefits. The Respondent, who was first notified of the accident by telephone call from the Applicant, mailed out the accident benefits package and continued to communicate with the Applicant via writing, despite not receiving any response from him. Since the Applicant never responded, it was not two-way communication. Moreover, the Applicant submitted a treatment confirmation form as well as a disability certificate during this period, which indicates a clear intention on behalf of the Applicant to claim benefits. The Respondent should have made other efforts to contact the Applicant to assist him with a claim that he clearly intended to proceed with.
29The above is all to say that the Applicant has a reasonable explanation for the delayed submission of his application. Pursuant to section 34 of the Schedule, the Applicant is not disentitled from receiving benefits if he has a reasonable excuse for the delay. In making the determination, I must remember that the Applicant holds the onus to establish a reasonable excuse, I must assess whether the explanation is credible of worthy of belief before considering its reasonableness, I must consider that ignorance of the law allow is not a reasonable explanation, that the test is both subjective and objective, that the lack of prejudice to the insurer does not make an explanation automatically reasonable, and that I must balance the prejudice to the insurer, the hardship to the claimant, and whether is it equitable to relieve against the consequences of the failure to comply with the time limit.
30In applying the above factors, I conclude that the Applicant’s excuse is reasonable, and he should be permitted to proceed with his claims. I genuinely believe and agree that the Applicant has established that he intended to apply for benefits and that the only reason the application was delayed is because his counsel faxed it to the incorrect number. His ignorance of the claims process is not the sole reason for the delay – it stems from a reasonable belief that his counsel was handling his claim. Here, it is equitable to permit the Applicant to proceed with his application for benefits in light of his counsel’s error, especially given that the prejudice to the Respondent is virtually nil if it is required to uphold its duty to adjust benefit claims from a consumer that was injured in an accident.
31Accordingly, I find that the Applicant may proceed with his application on the basis that the Respondent failed in its obligation to assist the Applicant in his claim, thus the 30-day filing requirement never started.
CONCLUSION AND ORDER
32The applicant may proceed with his application before the Tribunal.
Released: October 6, 2025
___________________________
Brian Norris
Adjudicator