Licence Appeal Tribunal File Number: 24-003590/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:
Saad Saleem
Applicant
and
Wawanesa Mutual Insurance Company
Respondent
DECISION
ADJUDICATOR: Aric Bhargava
APPEARANCES:
For the Applicant: Tal Eshel, Counsel
For the Respondent: Aliza Lalji, Counsel
HEARD: By way of written submissions
OVERVIEW
1Saad Saleem, the applicant, was involved in an automobile accident on April 19, 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 the respondent, Wawanesa Mutual Insurance Company, and applied to the Licence Appeal Tribunal — Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
PRELIMINARY ISSUE
2Is the applicant barred from proceeding to a hearing for all of the benefits claimed in this application because the applicant failed to dispute their denial within the two-year limitation period?
SUBSTANTIVE ISSUES
3The substantive issues in dispute are:
i. Are the applicant’s injuries predominantly minor as defined in section 3 of the Schedule and therefore subject to treatment within the $3,500.00 Minor Injury Guideline limit?
ii. Is the applicant entitled to the assessment and treatment plans/OCF-18 (“plan”) proposed by Prime Healthcare Inc., as follows:
a) $3,259.42 for physiotherapy services submitted May 17, 2019;
b) $2,000.00 for a psychological assessment submitted July 22, 2019;
c) $4,055.69 for psychological services submitted November 13, 2019; and
d) $1,809.80 for chiropractic services submitted January 13, 2020?
iii. Is the applicant entitled to interest on any overdue payments of benefits?
iv. Is the respondent liable to pay an award under section 10 of Regulation 664 because it unreasonably withheld or delayed payments to the applicant?
RESULT
4I find the applicant is statute-barred from proceeding with the substantive issues in dispute, as a result of his failure to dispute the denials within the two-year limitation period.
5The application is dismissed.
ANALYSIS
Preliminary Issue – Is the applicant statute-barred from proceeding?
6I find the applicant is statute-barred from proceeding to a hearing for all of the treatment plans in dispute.
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.
8However, in order for the provision under section 56 to be triggered, the respondent must have provided a proper notice of denial, in accordance with the principles set out in Smith v. Co-operators General Insurance Co., 2002 SCC 30 (“Smith”). Pursuant 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.
9The respondent submits that the applicant filed an appeal for benefits four years after the final explanation of benefits letter dated January 29, 2020. It argues the appeal is well beyond the two-year limitation period stipulated in section 56 of the Schedule and the applicant has not established reasonable grounds for an extension under section 7 of the Licence Appeal Tribunal Act, 1999 (the “LAT Act”).
10The applicant argues the denial was not valid because the respondent provided a boilerplate denial, and the limitation period is not to be applied in a rigid or inflexible manner.
Did the applicant fail to comply with the two-year limitation period?
11I find the applicant failed to dispute the denial of benefits within the two-year limitation period.
12There is no dispute that the applicant filed his application on March 20, 2024, and that the final denial letter was provided on January 29, 2020. I find that this is well outside of the two-year limitation period specified in section 56 of the Schedule.
13The applicant submits that section 56 was never triggered in the denial letter dated August 6, 2019 and the denial letter of November 14, 2019 because the respondent’s letters do not include medical reasoning for the denial, and the denial does not contain straightforward and clear language.
14Upon review of the denial notice dated August 6, 2019 for a psychological assessment, and November 14, 2019 for psychological services, I find that these notices satisfied requirements set out in Smith because each letter clearly refers to the applicant’s impairments, the specific treatment plan, whether the diagnosis falls within or outside of the MIG and provides sufficient reason for the denial. The August 6, 2019 letter states the applicant “did not report any psychological complaints” during the insurer’s examination, however, additional medical information may be submitted to support the claim. The November 14, 2019 letter states the applicant’s injuries are predominantly minor and the MIG limit applies.
15Moreover, the denial letters provide the applicant with information on his right to dispute and how to dispute the denials, including the relevant two-year time limit that governs the process.
16I find the reasons were clear and sufficient to allow an unsophisticated person to make an informed decision to either accept or dispute each of the denials.
17I find the denial letters are compliant with section 38(8) of the Schedule and the applicant failed to demonstrate how he complied with the two-year limitation period.
Are there reasonable grounds for an extension of the limitation period?
18Section 7 of the LAT Act allows the Tribunal to extend the limitation period outlined by section 56 in the Schedule, if it is satisfied, there are reasonable grounds for granting such relief. In determining whether to grant an extension, the Tribunal examines the following four factors set out in Manuel v. Ontario (Registrar, Motor Vehicle Dealers Act), 2012 ONSC 1492 (“Manuel”):
a) A bona fide intention to appeal within the limitation period;
b) The length of the delay;
c) Prejudice to the other party; and
d) Merits of the appeal.
19Manuel directs a holistic analysis of the factors where no single factor is determinative. The onus is on the applicant to establish if there are reasonable grounds for granting an extension.
20I will now assess each of the factors set out in Manuel.
Bona fide intention to appeal
21I find the applicant has not demonstrated a bona fide intention to appeal the benefit denials within the applicable limitation period.
22The applicant did not make submissions with respect to his intention to appeal within the limitation period.
23The respondent submits that the applicant did not communicate any intention to dispute the denial within the limitation period.
24Accordingly, I find the applicant has not established an intention to appeal within the limitation period.
The length of the delay
25I find that the delay in filing the application is significant. A delay of an additional two years beyond the prescribed two-year limitation, in my view, is not a relatively minor delay.
26Once again, the applicant did not make any submissions regarding the length of or the reason for the delay in filing the appeal.
27In my view, a delay of two years after the two-year time-limit to file an appeal without an explanation of circumstances or contextual information that may have contributed to this delay is significant.
28Accordingly, I am not satisfied that the delay is reasonable.
Prejudice to the other party
29Neither party has provided submissions of how they would be prejudiced.
Merits of the appeal
30I find the applicant’s appeal does not demonstrate sufficient merit to support an extension of the limitation period.
31The applicant submits that the section 25 psychological report dated October 30, 2019, prepared by Sandra Ramnaraine, psychotherapist, supervised by Dr. Andrew Shaul, psychologist, and the CNRs of St. Martha’s Regional Hospital and Dr. Bushra Farooq were not forwarded by the respondent to Dr. James Stewart, physician, for his section 44 report, dated July 11, 2019.
32The respondent has not made submissions on the matter of forwarding the CNRs for review, however, Dr. Farooq’s CNRs do not refer to the accident, and the CNRs of St. Martha’s Regional Hospital refer to chest, lower and mid-back pain and the x-ray results note “no evidence of acute traumatic injury” of the spine, thorax, or pelvis. I am not persuaded the CNRs support the applicant’s appeal.
33As discussed above, the denial letters dated August 6, 2019 and November 14, 2019 for a psychological assessment and psychological treatment state the benefit was denied because there is no corroborating medical evidence “of any (accident-related) psychological complaints” and “no mention of (accident-related) psychological concerns” in the medical documentation. In my view, there is not sufficient evidence to establish that an appeal or an extension for the limitation period is warranted.
34I find, on a holistic analysis of the Manuel factors, that an extension should not be granted. The applicant’s submission is primarily regarding one of the Manuel factors, and the Manuel factors are to be considered as a holistic test.
35Accordingly, the applicant is barred from bringing his application for the treatment plans in dispute, together with the corresponding interest and award, as he did not dispute the denials within the two-year limitation period in accordance with section 56. I have also found that the applicant has not established that an extension of the limitation period pursuant to section 7 of the LAT Act is warranted.
36As the only remaining substantive issue in dispute is a determination of whether the applicant’s injuries fall within the Minor Injury Guideline, which cannot be brought as a stan-alone issue, the application must be dismissed.
ORDER
37For the reasons outlined above, I find that the applicant is statute-barred from proceeding with his application.
38The application is dismissed.
Released: December 15, 2025
Aric Bhargava
Adjudicator