RECONSIDERATION DECISION
Before:
Melanie Malach, Adjudicator
Licence Appeal Tribunal File Number:
23-012513/AABS
Case Name:
Donna Matthews v. Intact Insurance Company
Written Submissions by:
For the Applicant:
Donna Matthews, Applicant Robin Russell, Applicant’s Spouse
For the Respondent:
Doug Wallace, Counsel
OVERVIEW
1On May 15, 2025, the applicant requested reconsideration of the Tribunal’s decision dated April 24, 2025 (“decision”).
2Stemming from an accident on January 28, 2016, the applicant sought benefits pursuant to the Statutory Accident Benefits Schedule – Effective September 1, 2010 (the “Schedule”). Following a written hearing, Adjudicator Matthew Frontini, found that, with respect to the preliminary issue in dispute, the applicant is barred from proceeding to a hearing for the medical and rehabilitation benefits claimed in her application because she did not dispute their denial within the two-year limitation period.
3The grounds for a request for reconsideration are found in Rule 18.2 of the Licence Appeal Tribunal Rules, 2023 (“Rules”). To grant a request for reconsideration, the Tribunal must be satisfied that one or more of the following criteria are met:
a) The Tribunal acted outside its jurisdiction or committed a material breach of procedural fairness;
b) The Tribunal made an error of law or fact such that the Tribunal would likely have reached a different result had the error not been made;
c) There is evidence that was not before the Tribunal when rendering its decision, could not have been obtained previously by the party now seeking to introduce it, and would likely have affected the result.
4The criteria cited by the applicant in support of her reconsideration request is Rule 18.2(b).
5The applicant is requesting that an order be granted reversing the decision of Adjudicator Frontini.
6The respondent asks for the request to be dismissed.
RESULT
7The applicant’s request for reconsideration is dismissed.
ANALYSIS
8I find that the applicant has not established grounds for reconsideration under Rule 18.2(b).
9At paragraph 14 of his decision, the adjudicator set out the relevant timeline in dispute as follows:
The relevant denials are dated August 29, 2018, for a treatment plan for chiropractic services dated July 16, 2018, and December 13, 2019, for a treatment plan for chiropractic services dated December 9, 2019. In the case of the denial for the August 29, 2018 treatment plan, the applicant applied to the Tribunal 3 years, 1 month, 19 days later. In the case of the denial for the treatment plan for chiropractic services dated December 9, 2019, the applicant applied to the Tribunal 3 years, 10 months, 5 days later.
10The applicant submits that the adjudicator made an error in law or fact which impacted his analysis. Specifically, the applicant submits that he erred at paragraph 34 of his decision where he found that, “she had the necessary information to dispute the denials and commence an application for these denied benefits within the statutory timelines”. The applicant submits that she did not receive the respondent’s statement of benefits because her address was not updated. She therefore did not have sufficient evidence to prove the amount of benefits available to her. She further submits that she did not have sufficient information upon which to challenge the denial of the treatment plans in dispute until May 9, 2021.
11The respondent submits that the adjudicator did not make an error of law or fact in his decision. It submits that the legal test was set out in the decision at paragraphs 7, 8 and 9. It submits that the law does not require the applicant to have sufficient evidence upon which to challenge a denial. The limitation period starts when an insurer gives a clear and unequivocal denial of a benefit that is accompanied by notice of the two-year period for commencing the dispute resolution process. The respondent further submits that, even if the applicant’s argument was accepted and the limitation period did not start running until May 9, 2021, the application would still be barred, as it was not filed until October 18, 2023, over two years and five months after May 9, 2021.
12In reply, the applicant submits that she filed her application with the Tribunal on January 13, 2023, which is within the 2-year limitation period from April 14, 2021. She further submits that it does not matter when the denial was made, because, in order to challenge a denial, she needs to know that there is something wrong with the reasons given for the denial and she has to be able to prove what was wrong. She submits that she did not know that there was anything wrong with the respondent’s denial until she received the respondent’s file in May 2025.
13The test for reconsideration under Rule 18.2 involves a high threshold. The reconsideration process is not an opportunity for a party to re-litigate its position where it disagrees with the Tribunal’s decision, or with the weight assigned to the evidence. The requestor must show how or why the decision falls into one of the categories in Rule 18.2. With this framework in mind, I find the applicant has not demonstrated how the criteria under Rule 18.2(b) has been engaged.
14I find the applicant has not directed me to any legal authorities stating that the analysis conducted was legally incorrect, nor has she shown how this analysis constitutes a factual error. Instead, the applicant appears to be requesting a reweighing of the evidence and a reassessment of her arguments at first instance. Both requests are not proper uses of the reconsideration process.
15The applicant does not direct me to any provision in the Schedule or caselaw that holds that it does not matter when a denial is made, as the insured person must have sufficient information upon which to challenge the denial. The legal test is whether the notices were compliant with the Schedule. At paragraphs 14, 15 and 16 of the decision, the adjudicator set out the relevant denial letters dated August 29, 2018 and December 13, 2019. The adjudicator found that both letters provided the reasons for the denial, included the treatment plan being denied and the applicant’s right to dispute addendum. The applicant’s argument that the denials were factually incorrect was dealt with in the decision at paragraph 31 where it was concluded that the respondent’s denials were not deficient. The adjudicator further found at paragraph 34 of the decision that the denials were clear and unequivocal, thereby triggering the commencement of the limitation period.
16With respect to the applicant’s submissions that she did not receive the denials at issue, the adjudicator found at paragraph 24 and 25 of the decision that the applicant had knowledge of the denials and it is undisputed that the applicant was represented by counsel at the date of these denials. The adjudicator dealt specifically with the applicant’s arguments that one of the denials was mailed to her former address and that the second denial had a typographical error in the address. The denials dated August 29, 2018, and December 13, 2019, were both faxed to the applicant’s legal representative, and in the case of the December 13, 2019 denial, an authorized representative, being a regulated health professional.
17For these reasons, I do not find that the applicant has demonstrated that the adjudicator erred in fact or law in his decision such that he would likely have reached a different result had the error not been made. As a result, the applicant’s request for reconsideration under Rule 18.2(b) is dismissed.
CONCLUSION & ORDER
18For the reasons set out above, the applicant’s request for reconsideration is dismissed.
Melanie Malach
Adjudicator
Tribunals Ontario – Licence Appeal Tribunal
Released: July 30, 2025