Licence Appeal Tribunal
Licence Appeal Tribunal File Number: 25-004570/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:
Laura Gonzalez
Applicant
and
Intact Insurance Company
Respondent
PRELIMINARY ISSUE HEARING DECISION AND ORDER
ADJUDICATOR: Trina Morissette, Vice-Chair
APPEARANCES:
For the Applicant: Kunwar S. Kohli, Counsel
For the Respondent: Megan Murphy, Counsel
HEARD: In writing
OVERVIEW
1Laura Gonzalez, the applicant, was involved in an automobile accident on August 15, 2019, and sought benefits from Intact Insurance Company, the respondent, 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 and applied to the Licence Appeal Tribunal (“the Tribunal”) for resolution of the dispute.
PRELIMINARY ISSUE IN DISPUTE
2The preliminary issue to be decided in this matter is whether the applicant is barred from proceeding to a hearing for all of the benefits claimed in this application because she failed to dispute the denials within the 2-year limitation period prescribed by section 56 of the Schedule?
RESULT
3The applicant did not dispute the denials within two years of receiving valid notices of denial pursuant to section 56 of the Schedule. She is accordingly barred from proceeding with her application.
BACKGROUND
4As described in the treatment plan (OCF-18) dated December 2, 2019, the applicant was the rear passenger of a vehicle that was rear-ended in a five-car collision on Highway 401. The applicant complained of headaches, neck pain, and upper and lower back pain, as a result of the accident.
5In addition to a claim that her injuries should be considered outside of the Minor Injury Guideline (“MIG”) and a claim for interest, there are three treatment plans in dispute in this matter:
i. A treatment plan submitted December 3, 2019, in the amount of $87.19 ($1,236.90 less $1,149.71 approved) for chiropractic services, proposed by Life Point Medical Inc., partially denied on December 16, 2019;
ii. A treatment plan submitted January 21, 2020, in the amount of $100.25 ($1,268.89 less $1,168.64 approved) for physiotherapy services, proposed by MedRehab Group, partially denied on January 31, 2020; and
iii. A treatment plan submitted July 30, 2020, in the amount of $1,304.55 for physiotherapy services, proposed by MedRehab Group, denied on August 19, 2020.
ANALYSIS
6For the reasons that follow, I find that the applicant did not dispute the denial/partial denials (“the denials/denial letters”) of these treatment plans within the 2-year limitation period and is therefore barred from proceeding to a hearing of her application.
7Section 56 of the Schedule provides that an application to the Tribunal in respect of a benefit shall be commenced within two years after the respondent’s refusal to pay the amount claimed. However, pursuant to section 7 of the Licence Appeal Tribunal Act, 1999, S.O. 1999, c. 12, Sched. G (the “LAT Act”), the Tribunal has the authority to extend the limitation period beyond the two-year mark outlined by section 56 of the Schedule.
8The parties do not dispute that the applicant filed her application with the Tribunal on April 4, 2025, which was well-beyond the 2-year limitation period. The applicant, however, submits that the denial letters were not compliant with section 38(8) of the Schedule in that the respondent failed to provide the medical reasons and/or supporting documentation to justify the denials. In the alternative, should the denials be deemed compliant, the applicant submits that she should be granted an extension of the limitation period because the respondent unreasonably delayed providing her with necessary information which would have allowed her to file an application within the statutory limitation period.
9The respondent submits that two of the treatment plans were partially approved and one denied, and it provided notice of same in correspondence to the applicant dated December 16, 2019, January 31, 2020 and August 19, 2020, respectively. It argues that these notices meet the criteria set out by the Schedule that trigger the 2-year limitation period, and the applicant, who filed her application with the Tribunal on April 4, 2025, is substantially past the limitation period to contest or dispute the partial denials.
The denials triggered the limitation period
10Section 38(8) of the Schedule, relied on by the applicant and which pertains to medical and rehabilitation benefits, states that within 10 business days of receiving a treatment plan, the insurer shall give the insured person notice outlining the medical reasons and all other reasons why the insurer considers any goods, services, assessments and examinations, or the proposed costs of them, not to be reasonable and necessary.
11The wording in section 56 of the Schedule which sets out the limitation period is different from section 38(8). In section 56, the only requirement for the 2-year limitation period to be triggered is that the insurer must refuse to pay the amount claimed. Section 56 does not require medical or any other reasons in order for the limitation period to begin (see Patton v. Aviva Insurance Co. of Canada, 2025 ONSC 4234 at para. 47).
12Here, in order for the partial denial notices to trigger section 56, it must comply with the principles set out in Smith v. Co-operators General Insurance Co., 2002 SCC 30 (“Smith”). According to Smith, the information in a denial notice must be provided in straightforward and clear language, directed towards an unsophisticated person. The information should also include a description of the most important points of the dispute resolution process, and the relevant time limits that govern the process.
13The applicant does not dispute that the letters were clear and/or unequivocal, or that there was information provided about the dispute resolution process, or even that they included information about the limitation period. The applicant relies solely on what she alleges was a lack of medical and “supporting documentation” provided pursuant to section 38(8). For clarification, section 38(8) does not reference “supporting documentation” but rather “medical reasons and all of the other reasons” for the denial.
14In all three denial letters, the respondent advised the applicant that her injuries fell within the designation of the MIG. The letters provided the definition of MIG, and advised that this designation carries a maximum medical and rehabilitation benefit limit of $3,500.00. The letters identify the individual treatment plans submitted and the amount for which they are partially denied or denied in full.
15In my view, the denial letters clearly and unequivocally explain the denial or partial denials in a way that an unsophisticated person would understand, and it is clear that the respondent would not be paying the remaining balances. As noted above, whether reference to the MIG satisfies the requirement of “medical reasons and all of the other reasons” stipulated at section 38(8) is not a consideration here.
16The letters also include “right to dispute” information setting out the process to dispute the partial denials. Regarding the 2-year limitation period, I note that the letters include the following:
If you are unable to resolve your dispute by written submission along with the exchange of important documents, you may apply to [the Tribunal] within two years of your insurer’s refusal to pay or redaction of a benefit.* […]
*WARNING: TWO YEAR TIME LIMIT
You have TWO YEARS from the date of your insurer’s refusal to pay, or reduction of a benefit, to file your application with [the Tribunal]. If you do not apply within two years, you will lose the right to dispute the determination.
17I find that the denial letters satisfy the requirements as set out in Smith. As such, the 2-year limitation period was triggered as of December 16, 2019, January 31, 2020 and August 19, 2020, respectively.
An extension of the 2-year limitation period is denied
18Section 7 of the LAT Act allows the Tribunal to extend a limitation period for filing an appeal. 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 (“Manuel”):
i. The existence of a bona fide intention to appeal within the limitation period;
ii. The length of delay;
iii. The prejudice to the other party; and
iv. The merits of the appeal.
19The onus is on the applicant to establish reasonable grounds for an extension under section 7 of the LAT Act.
Bona fide intention to appeal
20The applicant submits that the respondent’s actions/inactions caused the delay. More specifically, the applicant argues that the respondent failed to comply with section 44 of the Schedule by unreasonably delaying the release of the examination results, failing to communicate to the applicant the outcome following the examination, and neglecting to respond to repeated inquiries.
21For clarification, the “examination” the applicant relies upon is an examination under oath where the applicant was required to attend and provide information in a priority dispute between the respondent and another insurance company. Contrary to the applicant’s submissions, this was not an insurer’s examination pursuant to section 44.
22Priority disputes between insurers are separate from an application before the Tribunal and have no bearing on whether an insured is entitled to accident benefits.
23Regarding the factors set out in Manuel, the applicant submits that she had always intended to appeal the denial letters but was unable to proceed because she was awaiting a response from the respondent regarding the priority dispute. The applicant did not produce any of these communications. She explains that these communications were conducted via email and that, unfortunately, the applicant’s counsel changed his email address which resulted in no longer having access to them. The applicant submits that “it is reasonable to expect that the respondent can produce them upon request by the Tribunal.” I note that the applicant had the opportunity to request production of these emails at the time of the case conference. The CCRO specifically states at paragraph 7ii that the applicant made no such request.
24I am not persuaded by the applicant’s argument that she did not file her application within the 2-year limitation period because it was subject to the result of the priority dispute. As noted above, priority disputes are separate matters from applications before the Tribunal. The evidence before me supports that the applicant knew to contact the respondent regarding her accident benefits. The applicant submitted her treatment plans to the respondent, the respondent partially approved the treatment plans and provided notice to the applicant in this regard, and the applicant continued to correspond with the respondent.
25I also note that the applicant submits that information regarding the outcome of the priority dispute has not been communicated to her to this day, yet, the applicant filed her application with the Tribunal identifying the respondent as the insurer. In my view, it was clear that the applicant knew an application, filed within the 2-year limitation period and naming the respondent, was an available option to her.
26I further note that the applicant filed privileged information with her submissions which I have not reviewed or considered. The applicant submits that, since January 2024, her counsel sent multiple emails to the respondent regarding settlement of the matter and she provided these emails with her submissions. Section 15(2)(a) of the Statutory Powers Procedure Act, R.S.O. 1990, c. S.22 precludes the Tribunal from admitting evidence that would be inadmissible in a court by reason of any privilege under the law of evidence. The Tribunal has long recognized that settlement discussions are presumptively privileged and although privilege can be overridden in certain circumstances such as a waiver of privilege by all parties, there is no information provided that such a waiver exists here.
27I have therefore not reviewed these emails and decline to admit them into evidence for this preliminary issue hearing.
28In my view, the applicant has not satisfied me that she had a bona fide intention to appeal the partial denials. Although her submissions state that she did, submissions are not evidence, and as stated above, I do not agree that the priority dispute had any bearing on this matter.
Length of delay
29The applicant acknowledges that significant time has elapsed since the partial denials were provided but submits that this delay was caused by the respondent.
30As noted above, I am not persuaded that the delay in filing an application with the Tribunal was caused by the respondent and note that more than four years had passed from the date the respondent communicated its denials to the date the applicant filed her application. I find this to be a significant delay.
Prejudice to the respondent
31In its reply submissions, the respondent submits that it would be incurably prejudiced if these claims were allowed to proceed. I agree. Allowing the application to proceed introduces inherent prejudice to the respondent, who is entitled to rely on the limitation period. It would also present systemic prejudice and undermine the public interest in finality.
Merits of the appeal
32The applicant submits that all relevant medical records have been provided to the respondent, including a psychological rehabilitation screening report. She relies on Singh v. TD General Insurance Company, 2023 OABC para. 12728 (“Singh”) to argue that the threshold to satisfy this factor is low.
33I note that the authority submitted by the applicant is not a proper authority. The applicant provided a case summary prepared by Ontario Accident Benefit Cases. That being said, I agree with her that the threshold is a low one based on Singh (proper citation: Singh v. TD General Insurance Company, 2023 CanLII 9245). However, the applicant did not point me to any specific medical record she is relying on as evidence in this hearing to show that her application has merit and as per Singh, the onus remains with the applicant to show, through evidence, that there is some merit.
34As I have found above, submissions are not evidence. Without reference to specific medical evidence relied on by the applicant, I find that she has not persuaded me that there are merits to the application.
Summary of the Manuel factors
35In weighing the factors to determine if the matter warrants an extension of time under section 7, I find that the applicant has not met any of the four factors and therefore has not met her onus in demonstrating the limitation period should be extended. As such, I decline to use the discretion provided to me under section 7 of the LAT Act to extend the limitation period.
ORDER
36For the reasons provided above, the applicant is barred from proceeding to a hearing of her application. The application is dismissed.
Released: November 13, 2025
Trina Morissette Vice-Chair