Jones v. Intact Insurance Company, 2025 CanLII 5890

Citation: Jones v. Intact Insurance Company, 2025 ONLAT 22-013653/AABS

Licence Appeal Tribunal File Number: 22-013653/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:

Michelle Jones

Applicant

and

Intact Insurance Company

Respondent

DECISION

ADJUDICATOR: Ulana Pahuta

APPEARANCES:

For the Applicant: Adam Moftah, Counsel

For the Respondent: Dan Hynes, Counsel

HEARD: By way of written submissions

OVERVIEW

1Michelle Jones, the applicant, claims to have been involved in an automobile accident on February 14, 2018 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, 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 August 25, 2023, where the respondent raised two preliminary issues, including whether the applicant had committed a material misrepresentation as to whether she was involved in an “accident” as defined in s. 3(1) of the Schedule. The preliminary issues were set to be heard together with the substantive issues in dispute at this written hearing.

PRELIMINARY ISSUES

3The preliminary issues to be decided are:

1. Has the applicant committed a material misrepresentation under s. 53 of the Schedule as the applicant was not involved in an “accident” as defined in s. 3(1) of the Schedule? The respondent is seeking repayment of $10,516.57 pursuant to s. 52(1) of the Schedule.
2. Is the applicant barred from proceeding to a hearing for all of the benefits claimed in this application because she failed to dispute their denial within the 2-year limitation period as per s. 56 of the Schedule?

SUBSTANTIVE ISSUES

4The substantive issues to be decided in the hearing are:

1. Is the applicant entitled to $1,811.88 ($5,185.17 less $3,373.29 approved) for chiropractic and massage therapy services, proposed by Holistic Medical Clinic in a treatment plan (“OCF-18”) dated June 27, 2018?
2. Is the applicant entitled to $4,831.27 for chiropractic and massage therapy services, proposed by Holistic Medical Clinic in an OCF-18 dated October 10, 2018?
3. Is the applicant entitled to $3,273.24 for chiropractic and massage therapy services, proposed by Holistic Medical Clinic in an OCF-18 dated July 30, 2019?
4. Is the respondent liable to pay an award under s. 10 of Regulation 664 because it unreasonably withheld or delayed payments to the applicant?
5. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

5I find that:

i. the applicant was involved in an accident and did not commit a material misrepresentation under s. 53 of the Schedule. The respondent is not entitled to repayment of $10,516.57 pursuant to s. 52(1) of the Schedule;

ii. the applicant is barred pursuant to s. 56 of the Schedule from proceeding to a hearing on the substantive issues because she failed to dispute their denial within the 2-year limitation period; and

iii. the applicant is not entitled to an award.

6The application is dismissed.

ANALYSIS

The applicant was involved in an “accident” as defined in s. 3(1) of the Schedule and did not commit a material misrepresentation

Background

7The parties disagree as to the factual circumstances of the incident that took place on February 14, 2018.

8The applicant submits that she had been crossing the street as a pedestrian, when she was hit on the left side at a low