Matthews v. Intact Insurance, 2025 CanLII 35938

Citation: Matthews v. Intact Insurance, 2025 ONLAT 23-012463/AABS

Licence Appeal Tribunal File Number: 23-012463/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.

Parties

Between:

Donna Matthews Applicant

and

Intact Insurance Company Respondent

DECISION

ADJUDICATOR: Melanie Malach

APPEARANCES:

For the Applicant: Donna Matthews, Applicant Robin Russell, Applicant’s Spouse

For the Respondent: Doug Wallace, Counsel

HEARD: By way of written submissions

OVERVIEW

1Donna RR Matthews, the applicant, was involved in an automobile accident on August 1, 2014, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (the “Schedule”). The applicant was denied benefits by the respondent, Intact Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.

2A case conference was held on February 21, 2024, where both preliminary and substantive issues were raised. The preliminary issue was set to be heard together with the substantive issues in dispute at this written hearing.

PRELIMINARY ISSUE

3The preliminary issue to be decided is:

1. Does the Tribunal have jurisdiction under s. 280 of the Insurance Act, RSO 1990 (“Insurance Act”) with respect to the applicant’s entitlement to $45,054.65, which is the balance of the $50,000.00 policy limit?

SUBSTANTIVE ISSUES

4The substantive issues in dispute are:

i. Is the applicant entitled to $45,054.65 which is the balance of the $50,000.00 policy limit?

ii. Is the applicant entitled to interest on any overdue payment of benefits?

iii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?

RESULT

5The Tribunal does not have jurisdiction to grant the relief sought. The application is dismissed.

BACKGROUND

6The applicant was involved in two motor vehicle accidents, one on August 1, 2014, and another on January 28, 2016. This application is in respect of the 2014 accident.

7The applicant’s file was closed by the respondent due to inactivity on March 29, 2017. The respondent submits that it converted to a new computer system and assigned a new claim number on July 11, 2017. The applicant submits that this is incorrect, and the file was closed on July 11, 2017. The parties agree that the file was then re-opened by the respondent upon receipt of a new treatment plan on May 9, 2019, and remains open.

8The applicant claims the full amount of the remaining medical and rehabilitation limits in the amount of $45,054.65.

PARTIES’ POSITIONS

9The applicant claims entitlement to $45,054.65, which is the balance of the medical and rehabilitation limits under her policy with the respondent as of the date of the applicant’s application. She claims that the Tribunal has the jurisdiction to award her this amount in statutory accident benefits. The applicant submits that based on s. 280(1) of the Insurance Act, the Tribunal has jurisdiction to resolve disputes about injured people’s entitlement to accident benefits or how much that person was entitled to. She argues that her right and entitlement to these benefits was taken away when the respondent improperly closed her claim. The applicant submits that if a dispute relates to the insurer’s compliance with obligations to the insured, the timeliness of performance of those obligations, and/or the manner in which they were administered, this falls within the jurisdiction of the Tribunal. The applicant relies upon the Court of Appeal decision in Morgan Stegenga v. Economical Mutual Insurance Company, 2019 ONCA 615.

10The respondent submits that section 280 of the Insurance Act grants the Tribunal jurisdiction to resolve disputes (i) in respect of an insured person’s entitlement to statutory accident benefits or (ii) in respect of the amount of statutory accident benefits to which an insured person is entitled, in accordance with the Schedule. The respondent argues that the authorizing statute requires a dispute with respect to an insured person’s entitlement to or amount of a statutory accident benefit for the Tribunal to have jurisdiction. Absent a dispute, the Tribunal lacks jurisdiction to hear the matter because there is no dispute to resolve. The respondent relies upon the Tribunal decision in Balachandran v. Economical Insurance, 2022 CanLII 124644 (ON LAT).

11The respondent further submits that there is no live dispute with respect to the applicant’s entitlement to statutory accident benefits. The respondent submits that the applicant is claiming the monetary limits as her entitlement instead of complying with the process for claiming benefits set out in sections 15, 16, 38 and 39 of the Schedule. The respondent submits that the applicant must first apply for benefits through the process mandated by the Schedule. If her claim is denied, she then may apply to the Tribunal to resolve a dispute in accordance with s. 280(2) of the Insurance Act, but not before.

12The applicant in her reply submissions states that there was a treatment plan in dispute at the time of her application which was subsequently resolved at the Case Conference. As such, she submits that there is clearly a dispute in this matter and the Tribunal has jurisdiction to deal with the current issues in dispute.

ANALYSIS

13I find that the Tribunal does not have jurisdiction to hear this application.

14The Tribunal’s jurisdiction is derived from s. 280(2) of the Insurance Act which pertains to the resolution of disputes regarding statutory accident benefits in accordance with the Schedule. Where an insurer denies a benefit, the insured person can apply to the Tribunal for resolution of the dispute, as described in s. 280(1) of the Insurance Act. Subsection (1) refers to disputes regarding an insured person’s entitlement to statutory accident benefits or in respect to the amount of statutory accident benefits to which an insured person is entitled. I find that in the present matter, there has been no request for a benefit submitted and denied and therefore there is no “dispute” as defined in s. 280 of the Insurance Act. If there is no dispute, then the Tribunal has no jurisdiction. In the matter before me, there are no treatment plans in dispute and there is no other benefit in dispute, that has been denied by the respondent. Therefore, there is no dispute with respect to the applicant’s entitlement to a statutory accident benefit or in respect of the amount of that statutory accident benefit.

15I further find that the applicant has not identified any provision in the Schedule or other authority in support of the proposition that an insured person is entitled to funds up to the limits of funding for medical and rehabilitation benefits, without reference to a specific claim for benefits. The funding limits are not a benefit under the Schedule, and the Schedule does not contemplate such a payment.

16I further find that while there was a dispute about entitlement to a treatment plan at the time of the applicant’s application, this issue was resolved at the Case Conference and was no longer in dispute or listed as an issue in dispute. The Tribunal can only deal with the issues before it. As this issue is not listed on the Case Conference Report and Order, it is not before me.

17As such, I find that the Tribunal does not have jurisdiction to adjudicate the issue of whether the applicant is entitled to the remaining medical and rehabilitation benefit limits, and as such, the issue cannot proceed to the substantive portion of the hearing.

ORDER

18For the reasons set out above, I find that the Tribunal does not have the jurisdiction to hear this application. The application is dismissed.