Licence Appeal Tribunal File Number: 25-008861/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:
Jeffrey Masters
Applicant
and
Travelers Insurance Company of Canada
Respondent
PRELIMINARY ISSUE DECISION AND ORDER
ADJUDICATOR:
Trina Morissette, Vice-Chair
APPEARANCES:
For the Applicant:
Christopher R. Dawson, Counsel
For the Respondent:
David Raposo, Counsel
HEARD: In writing
OVERVIEW
1Jeffrey Masters, the applicant, was involved in an automobile accident on June 16, 2021, and sought benefits from Travelers Insurance Company of Canada, 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 in dispute is whether the applicant is barred from proceeding with his claim for benefits as he failed to submit his application for benefits (OCF-1) within the time prescribed in the Schedule.
RESULT
3The applicant is barred from proceeding with his application.
ANALYSIS
4Section 32(1) of the Schedule provides that a person who intends to apply for accident benefits shall notify the insurer of their intention no later than the seventh day after the circumstances arose that give rise to the entitlement to the benefit, or as soon as practicable after that day.
5Once an insurer receives notice of an applicant’s intention to apply for statutory accident benefits, the insurer must provide the applicant with the appropriate OCF-1 forms, a written explanation of the benefits available, information to assist the person in applying for the benefits and information on the election relating to the specified benefits, if applicable (section 32(2)). Pursuant to section 32(5) of the Schedule, the applicant must then submit a completed and signed application for benefits to the respondent within 30 days after receiving the forms.
6Section 34 of the Schedule states that “a person’s failure to comply with a time limit set out in this Part does not disentitle the person to a benefit if the person has a reasonable explanation.” The onus is on the applicant to establish a reasonable explanation for the delay. The interpretation of “reasonable explanation” is guided by Horvath and Allstate Insurance Company of Canada, 2003 ONFSCDRS 92 and was reiterated in K.H. v. Northbridge, 2019 CanLII 101613 (ON LAT) (“K.H.”). The guiding principles are summarized as follows:
a. An explanation must be determined to be credible or worthy of belief before its reasonableness can be assessed;
b. The onus is on the insured person to establish a “reasonable explanation”;
c. Ignorance of the law alone is not a “reasonable explanation”;
d. The test for “reasonable explanation” is both a subjective and objective test that should take account of both personal characteristics and a “reasonable person” standard;
e. The lack of prejudice to the insurer does not make an explanation automatically reasonable; and
f. An assessment of reasonableness includes a balancing of prejudice to the insurer, hardship to the claimant and whether it is equitable to relieve against the consequences of the failure to comply with the time limit.
7Pursuant to an affidavit sworn by the applicant on November 12, 2025, the applicant is a self-employed and part-owner of a towing and repair company in Woodstock, Ontario. On June 16, 2021, the applicant was operating a large tow truck and responded to a service call. While preparing the flatbed, a third-party seated in the vehicle to be towed, accidentally accelerated up the ramp and onto the flatbed, striking the applicant.
8The applicant was transported to hospital by ambulance and then transferred to a second hospital as a trauma patient. He was diagnosed with multisystem trauma, including an open depressed left parietal skull fracture, a left mandible fracture requiring surgery, rib fractures, an inferior pubic ramus fracture, lacerations to his scalp and left ear, and abrasions to his right leg.
9The parties do not dispute the applicant notified the respondent of the accident on June 18, 2021. There is also no dispute that the applicant submitted his application (dated June 14, 2023) to the respondent on June 15, 2023, one day shy of two years from the date of the accident.
10The question before me is whether the applicant provided a reasonable explanation for his delay in submitting his OCF-1.
11In a letter from applicant’s counsel to the respondent dated June 29, 2023, the applicant provided the following explanation:
Further to your letter dated June 19, 2023, I can advise that our office was first contacted by [the applicant] on May 16, 2023. Our initial telephone call with [the applicant] occurred on May 17, 2023, and I subsequently met with [the applicant] in Woodstock on May 25, 2023. This was his first conversation with a lawyer about his rights.
My office began working on [the applicant’s] Application for Accident Benefits right away to ensure that the OCF-1 was submitted as soon as possible. While [the applicant] did initially receive an Accident Benefits Application package on or about June 23, 2021, at the time he was convalescing from significant personal injuries including a serious head injury requiring surgery along with a number of fractures. He did not fully appreciate or understand the information provided, the significance of the nature of his injuries or the fact that he would be continuing to suffer from his injuries over two years later.
Once [the applicant] had a better understanding of the longevity of his injuries, he contacted our office for assistance.
12The respondent submits that while it acknowledges the applicant sustained “some legitimate and objective injuries”, the applicant’s explanation is not credible or worthy of belief. It concedes that in the first few weeks following the accident the applicant was convalescing from his injuries, the adjusters’ log notes reflect that the applicant reported doing “just fine” and that he was “not going for any treatment”. The applicant reported being told by his doctor that he did not need any treatment and that, as early as August 31, 2021, he reported he was back at work and would not be submitting a claim. The respondent argues that to now suggest, years later, that he did not learn of his legal rights arising from the accident until he spoke with his counsel on May 25, 2023 is not credible or worthy of belief.
13The applicant submits that his explanation is credible, reasonable, and supported by compelling medical and factual evidence. He argues that a reasonable person in his position – hospitalized with severe injuries, recovering from surgery, unable to return to his usual employment and struggling with memory and cognitive deficits – would not likely have been aware of the availability of this type of insurance coverage in the absence of clear legal guidance. Upon recognizing the seriousness of his condition, he acted promptly and the timeline demonstrates diligence once he became aware of his rights and the permanence of his impairments.
14I am not persuaded that the applicant’s impairments following the accident prevented him from submitting his OCF-1 before June 15, 2023. In his submissions, the applicant makes several references to the onus resting with him to establish a reasonable explanation. He submits that he discharged this burden through his sworn affidavit evidence, contemporaneous hospital records and expert reports spanning 2023 to 2025. He submits that his explanation is consistent with the medical trajectory documented in these records. However, the applicant did not submit any medical documentation with his submissions.
15The applicant submits that an Ambulance Call Report confirms the paramedics documented he was amnestic at the scene, that the Emergency Department notes describe his head injury as “significant”, and that he was discharged home under significant physical and cognitive limitations. He states that the description of his injuries is also supported by a speech-language pathology report dated November 2023, an oral surgery report dated November 2024, a neuropsychological assessment report dated April 2025 which “confirms at minimum, a mild traumatic brain injury, depression, and chronic pain.” He alleges the neuropsychological report also documents post-traumatic amnesia, impaired verbal memory and reduced initiation, deficits he submits directly impacted his ability to process complex information and the significance of the accident benefit forms sent to him following the accident. None of these documents were submitted to the Tribunal for review.
16I have considered the possibility that the applicant’s failure to submit medical documentation was due to an oversight. However, not only do the applicant’s submissions fail to specifically reference any document submitted, the totality of the documents he submitted consists of caselaw and a sworn affidavit with no exhibits, suggesting there was no intention of filing his medical documentation with his submissions.
17I acknowledge that the applicant relies on his sworn affidavit which summarizes his injuries and his medical trajectory after the accident, however, I assign little weight to this evidence as the evidence provided in the affidavit is also not supported by any medical documentation. The applicant’s failure to submit the medical documentation hinders the Tribunal’s review of this evidence and the applicant’s reliance on it. I find this particularly unpersuasive as the log notes indicate the applicant returned to work as early as July 2021, on modified duties, where he managed office-based work for the business, including paperwork. It is unclear how the applicant could complete these duties but not complete his OCF-1.
18To be clear, I accept that the applicant sustained significant physical impairments due to the accident, as the respondent does not dispute this fact. What I find the applicant has not sufficiently shown is that these physical impairments persisted over two years, developed into psychological and cognitive impairments, to the extent that they hindered his ability to complete his application before he did so on June 15, 2023. Even if I accepted that the applicant was initially overwhelmed with his medical condition immediately following the accident and that he was dependent on others for care, I am not persuaded that this explains the significant delay of two years.
19The applicant also submits that the respondent failed to follow up with him after further time elapsed to inquire of his status, and he argues that the internal log notes are self-serving, limited, uninformed and do not undermine medical opinions. In response, the respondent submits it was in regular contact with the applicant within days of the accident, it provided him with the required accident benefits package, and there is no evidence or information that the respondent, in any way, failed to fulfil its obligation of good faith.
20I do not accept the applicant’s characterization of the log notes and agree with the respondent that the log notes serve, in part, to contemporaneously document the content of conversations between the applicant and the respondent. Here, the log notes indicate:
i. On June 18, 2021, the respondent is notified of the accident. The respondent is advised that the applicant is in hospital with a “cracked skull, broken jaw & ribs etc. but is awake and able communicate.”
ii. On June 22, 2021, the respondent contacts its client (the auto repair/towing company) and confirms the details of the accident.
iii. On June 23, 2021, the respondent spoke to the applicant’s wife who advised that the applicant had undergone a 6-hour jaw surgery and was not speaking much. The respondent advised her that it would be sending out the accident benefits package.
iv. Later that same day, the applicant contacted the respondent by telephone. He confirmed his injuries (fractured skull, broken jaw, broken ribs, pelvic area, left shoulder, and left ear), but advised that he didn’t recall the accident. He advised that his wife was helping him with personal care and “everything”, he was not certain yet if his income would be impacted, and he was out-of-pocket for a walker, cane and ambulance expenses. The respondent offered the applicant an in-home occupational therapy assessment but the applicant declined. The applicant confirmed he would contact the respondent if he had any questions with the “paperwork” provided to him.
v. The respondent sent an accident benefits package to the applicant on June 23, 2021. The letter states, in part, “[i]n order to claim accident benefits, you must submit your completed Application for Accident Benefits (OCF-1) within 30 days of receiving this letter.”
vi. On June 30, 2021, the respondent contacted the applicant by telephone to follow-up on how he was doing, whether he received the “paperwork” and what, if any, follow-up with his doctors. The applicant advised, in part, that he had additional upcoming medical appointments, was still using a walker, his wife was still taking care of him, and he had not yet returned to work. The applicant advised he had not yet received the accident benefits package. The respondent’s adjuster advised she would contact him again in a week.
vii. On July 6, 2021, the respondent followed up with the applicant by telephone, however, someone by the name of Doug answered. Doug advised that the applicant confirmed he had received a package and was expecting a phone call. The respondent’s adjuster left her contact information and asked to let the applicant know she had called.
viii. In correspondence dated July 27, 2021, the respondent advised the applicant that it had not yet received his completed application and reminded him: “you are required to submit a completed and signed application for benefits to the insurer within 30 days after receiving the application forms.” The applicant could contact the respondent should he require additional time or assistance. The letter also stated that “[i]f we do not hear from you by August 26, 2021 we will assume you do not wish to present a claim and will close your file.”
ix. On July 29, 2021, the respondent contacted the applicant by telephone. Included in the update provided by the applicant, he advised the respondent he was working on the “paperwork”, some of which had been sent to a doctor, and he hoped to have it to the respondent within the week. He also provided an update on his physical impairments including: he had another jaw appointment coming up; he was not using his walker/cane unless he felt sore or tired; and he was not taking any medication. The applicant also advised that he had partially returned to work. He clarified that he was not driving the truck or doing any pick-ups, rather, he was answering the telephone and doing paperwork. He had returned to driving his personal vehicle.
x. The last conversation between the applicant and the respondent was on August 31, 2021. The log note states, in part:
we were able to speak
he is doing just fine – not going for any treatment – doctor said did not need any treatment
back at work – didn’t lose any income
he is not submitting a claim
21Pursuant to Hussein v. Intact Insurance Company, 2025 ONSC 842 (“Hussein”), an interpretation of section 32(1) must recognize the reality that consumers who have motor vehicle accidents are in a vulnerable position, particularly in the period immediately following the accident. Hussein provides that the insurer has a positive obligation to inquire and assist an insured person with their application for accident benefits and affirms that insurers cannot simply rely on the insured person’s inaction to determine that no benefits will be claimed.
22In my view, the follow-ups made by the respondent to the applicant regarding the anticipated OCF-1 satisfy the positive duty under Hussein. The respondent acknowledged the injuries reported by the applicant as well as the surgery he underwent and extended the 30-day timeline of section 32(5) until August 31, 2021, at which time the applicant confirmed he would not be submitting an application for accident benefits.
23Although the applicant, at some point after the mailing of the accident benefits package, advised the respondent that he had not received it, later log notes suggest he eventually did. Furthermore, applicant’s counsel’s letter of June 29, 2023 acknowledged that the applicant received the accident benefits package provided to him on June 23, 2021.
24I note that much is made in the parties’ submissions on whether the applicant is, or is not, a sophisticated insured. The respondent submits that he is a sophisticated insured because he completed high school, attended one year of post-secondary education, became a mechanic and was a part-owner of the business. The applicant argues that his education, experience and physical and psychological injuries lend credence to the facts that he was genuinely ignorant of the availability of accident benefits coverage through the insurance policy he held. He submits he is unsophisticated in this area and relied on others for assistance following the accident. The applicant acknowledges that ignorance of the law is not sufficient, but when combined with cognitive impairment and a lack of legal advice, it becomes a compelling factor.
25I am not persuaded by the applicant’s argument above. In my view, a significant number of Ontarians are non-educated on the topic of accident benefits which is why the Schedule (at section 32(2)) and the Court (in Hussein) have imposed obligations on insurers to provide an accident benefits package and a positive duty to inquire and assist. Here, I find the respondent fulfilled these requirements. Additionally, as previously noted, there is no medical documentation before me confirming any cognitive impairment to support the applicant’s allegation.
26An assessment of reasonableness includes a balancing of prejudice to the respondent, hardship to the applicant, and whether it is equitable to relieve against the consequences of the failure to comply with the time limits at section 32. The applicant submits that the prejudice to the respondent is minimal when weighed against the severe hardship he would suffer should his claim be barred. The respondent has access to contemporaneous hospital records documenting the nature and severity of the applicant’s injuries and therefore, whether the respondent assessed the applicant in 2021 or 2023, the applicant argues that the outcome would be the same. I disagree. The respondent could not arrange for section 44 insurer’s examinations without the applicant submitting a complete application. In this case, the OCF-1 was only submitted on June 15, 2023, two years following the accident which I find is a significant delay, and which impaired the respondent’s ability to properly assess the applicant for, at least, the first two years following the accident.
27Taking into account the principles of K.H., I find that the applicant has not provided medical documentation to support that he was unable to fulfil the requirements of section 32, ignorance of his rights is not sufficient on its own, his allegation that the respondent did not assist or provide necessary information is not credible, and the delay of two years before submitting his completed OCF-1 is significant. His delay has caused prejudice to the respondent in fulfilling its obligations to investigate and assess his claim.
28For these reasons, I find that the applicant has not met his onus to establish a reasonable explanation for his delay.
Section 55
29Pursuant to section 55(1)1 of the Schedule, an insured person shall not apply to the Tribunal under section 280(2) of the Insurance Act if the insured person has not notified the insurer of the circumstances giving rise to the claim or has not submitted an application for the benefit within the time limits prescribed in section 32.
30As outlined above, I find that the applicant did not submit an application for benefits within the timeline prescribed by the Schedule and he has not provided a reasonable explanation for the delay. Accordingly, I find that the applicant is statute-barred from proceeding with his application before the Tribunal.
ORDER
31The applicant is barred by section 55(1) from proceeding with his application before the Tribunal. The Tribunal shall vacate any date that has been scheduled for the substantive issues hearing.
Released: March 26, 2026
Trina Morissette
Vice-Chair