Pedro Gonzalez v. Intact Insurance Company, 2025 CanLII 116972

PRELIMINARY ISSUE HEARING DECISION AND ORDER

Citation: Gonzalez v. Intact Insurance Company, 2025 ONLAT 25-004566/AABS -PI

Licence Appeal Tribunal File Number: 25-004566/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:

Pedro Gonzalez

Applicant

and

Intact Insurance Company

Respondent

ADJUDICATOR: Trina Morissette, Vice-Chair

APPEARANCES:

For the Applicant: Kunwar S. Kohli, Counsel

For the Respondent: Megan Murphy, Counsel

HEARD: In writing

OVERVIEW

1Pedro 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 he 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. He is accordingly barred from proceeding with his application.

BACKGROUND

4As described in the treatment plan (OCF-18) dated December 9, 2019, the applicant was the driver of a vehicle that was rear-ended in a five-car collision on Highway 401. His spouse and daughter were also in the vehicle. The applicant complained of headaches, neck pain, low back pain, as well as right and left shoulder pain, as a result of the accident. An ultrasound of the right shoulder dated August 31, 2019, indicated a tear of the right supraspinatus tendon and right subscapularis tendon.

5In addition to a claim that his 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 10, 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 January 3, 2020;

ii. A treatment plan submitted January 21, 2020, in the amount of $100.25 ($886.02 less $785.77 approved) for physiotherapy services, proposed by MedRehab Group, partially denied on January 31, 2020; and

iii. A treatment plan submitted January 7, 2021, in the amount of $1,706.00 for physiotherapy services, proposed by MedRehab Group, denied on January 26, 2021.

6I note that the Case Conference Report and Order (“CCRO”) dated August 6, 2025 indicates that the second treatment plan above is dated January 21, 2022. I have reviewed the treatment plan in question and confirm that the correct date is 2020 and not 2022.

ANALYSIS

7For 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 his application.

8Section 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.

9The parties do not dispute that the applicant filed his 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 he should be granted an extension of the limitation period because the respondent unreasonably delayed providing him with necessary information which would have allowed him to file an application within the statutory limitation period.

10The 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 January 3, 2020, January 31, 2020, and January 26, 2021, respectively. It argues that these denial letters meet the criteria set out by the Schedule that trigger the 2-year limitation period, and the applicant, who filed his application with the Tribunal on April 4, 2025, is substantially past the limitation period to contest or dispute the denials.

The denials triggered the limitation period

11Section 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.

12The 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).

13Here, in order for the denials to trigger section 56, they 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.

14The 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 he 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.

15In all three denial letters, the respondent advised the applicant that his injuries fell within the designation of the Minor Injury Guideline (“MIG”). The denial letters provided the definition of MIG and advised that this designation carries a maximum medical and rehabilitation benefit limit of $3,500.00. The denial letters identify the individual treatment plans submitted and the amount for which they are partially denied or denied in full.

16In 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.

17The letters also include “right to dispute” information setting out the process to dispute the 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.

18I find that the denial letters satisfy the requirements as set out in Smith. As such, the 2-year limitation period was triggered as of January 3, 2020, January 31, 2020 and January 26, 2021, respectively.

An extension of the 2-year limitation period is denied

19Section 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.

20The onus is on the applicant to establish reasonable grounds for an extension under section 7 of the LAT Act.

Bona fide intention to appeal

21The 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.

22For clarification, the “examination” the applicant relies upon is an examination under oath where an individual (other than the applicant, who was also involved in the subject accident), 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.

23Priority disputes between insurers are separate from an application before the Tribunal and have no bearing on whether an insured is entitled to accident benefits. In addition, there is no information that this priority dispute involved the applicant.

24Regarding the factors set out in Manuel, the applicant submits that he had always intended to appeal the denial letters but was unable to proceed because he was awaiting a response from the respondent regarding the priority dispute. The applicant did not produce any of these communications. He 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.

25I am not persuaded by the applicant’s argument that he did not file his 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 his accident benefits. The applicant submitted his treatment plans to the respondent, the respondent either partially approved or denied the treatment plans and provided notice to the applicant in this regard, and the applicant continued to correspond with the respondent.

26I also note that the applicant submits that information regarding the outcome of the priority dispute has not been communicated to him to this day, yet, the applicant filed his 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 him.

27I further note that the applicant filed privileged information with his submissions which I have not reviewed or considered. The applicant submits that, since January 2024, his counsel sent multiple emails to the respondent regarding settlement of the matter and he provided these emails with his 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.

28I have therefore not reviewed these emails and decline to admit them into evidence for this preliminary issue hearing.

29In my view, the applicant has not satisfied me that he had a bona fide intention to appeal the denials. Although his submissions state that he did, submissions are not evidence, and as stated above, I do not agree that the priority dispute (which appeared to be related to another individual) had any bearing on this matter.

Length of delay

30The applicant acknowledges that significant time has elapsed since the denials were provided but submits that this delay was caused by the respondent.

31As 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 his application. I find this to be a significant delay.

Prejudice to the respondent

32In 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

33The applicant submits that all relevant medical records have been provided to the respondent, including a psychological rehabilitation screening report. He relies on Singh v. TD General Insurance Company, 2023 OABC para. 12728 (“Singh”) to argue that the threshold to satisfy this factor is low.

34I 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 him 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 he is relying on as evidence in this hearing to show that his application has merit and as per Singh, the onus remains with the applicant to show, through evidence, that there is some merit.

35As I have found above, submissions are not evidence. Without reference to specific medical evidence relied on by the applicant, I find that he has not persuaded me that there are merits to the application.

Summary of the Manuel factors

36In 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 his 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

37For the reasons provided above, the applicant is barred from proceeding to a hearing of his application. The application is dismissed.