Licence Appeal Tribunal File Number: 25-008797/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:
Pamela Beattie
Applicant
and
Intact Insurance Company
Respondent
PRELIMINARY ISSUE HEARING DECISION AND ORDER
ADJUDICATOR:
Melanie Malach
APPEARANCES:
For the Applicant:
Shane Henry, Counsel
For the Respondent:
Jeffrey Booth, Counsel
Heard:
By way of written submissions
OVERVIEW
1Pamela Beattie, the applicant, was involved in an accident on October 3, 2023, 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.
PRELIMINARY ISSUES IN DISPUTE
2The preliminary issues to be decided is:
i. Is the applicant barred from proceeding to a hearing as she failed to notify the respondent of the circumstances giving rise to a claim for benefits no later than the seventh day after the circumstances arose or as soon as practicable after that day?
RESULT
3The applicant is not barred from proceeding to a hearing.
ANALYSIS
The Law
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 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, pursuant to s. 32(2) of the Schedule, the insurer must provide the applicant with the appropriate OCF-1 forms, a written explanation of benefits available, information to assist the person in applying for benefits and information on the election relating to income replacement benefits, non-earner and caregiver benefits, if applicable. Pursuant to s. 32(5) of the Schedule, the applicant must then submit a completed and signed application for benefits to the insurer within 30 days after receiving the application 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.
7The interpretation of “reasonable explanation” is guided by Horvath v. Allstate Company of Canada, 2003 ONFSCDRS 92 (“Horvath”) and was more recently reiterated in K.H. v. Northbridge General Insurance Company, 2019 (“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 explanation” standard.
e. The lack of prejudice to the insurer does not make an explanation automatically reasonable.
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 limits.
8Pursuant to section 55(1)1 of the Schedule, an insured person may not apply to the Tribunal if they have not notified the insurer of the circumstances giving rise to a benefit or has not submitted an application for the benefit within the times set out in the Schedule.
Background
9The applicant was involved in the subject accident on October 3, 2023.
10By correspondence dated December 31, 2024, counsel for the applicant advised the respondent that it had been retained to pursue an accident benefits claim on behalf of the applicant for an accident on October 3, 2023. An Application for Accident Benefits (“OCF-1”) was enclosed.
11By correspondence dated January 13, 2025, the respondent sent a reservation of rights letter to the applicant noting that they are investigating the claim based on the late notice pursuant to s. 32(1) of the Schedule. The letter notes that the applicant “initially informed us there were no injuries and it wasn’t until December 31, 2024, you advised us that you were injured in the accident”. Section 33 requests were made for records of her family doctor or walk-in clinic, hospital and ambulance records, a Police Report and a statement to address loss details and late reporting.
12The applicant provided a telephone statement to the respondent that was taken on February 14, 2025 and March 20, 2025. She noted,
The reason for the late reporting of this accident benefits claim to my insurer is due to my emotional health since the accident and this can be confirmed through my medical records. It was overwhelming and shutting me down and all the changes that came were overwhelming to try to navigate and understand. I would get overwhelmed and not be able to function. The post-concussion symptoms and emotional health have been overwhelming me and adding to the delay.
13On May 9, 2025, the respondent requested a copy of the Police Report to assist in its investigation. On May 12, 2025, the respondent asked for missing documentation and clarification regarding the accident details.
14By letter dated May 21, 2025, the respondent denied the applicant’s coverage based on non-compliance with s. 32(1) of the Schedule.
Parties’ Positions
15The respondent submits that the applicant’s reasons for the late reporting set out in her Statement do not meet the threshold of a reasonable explanation under s. 34 of the Schedule. The respondent submits that the applicant had the capacity to take steps to notify the respondent well before December 31, 2024. It argues that her abilities and functioning following the accident weighs heavily against a finding that she was incapable of contacting the respondent in a timely manner.
16The respondent provides a detailed summary of the applicant’s Clinical Notes and Records (“CNRs”) from Mamaway Wiidokaadwin Medical Clinic, following the subject accident from October 4, 2023 to December 6, 2024. The respondent argues that any suggestion that the applicant was unable or somehow continually prevented from even notifying the respondent of the accident is hard to reconcile when the records support and demonstrate that following the accident she was capable of attending various appointments, sending and receiving emails, pursuing her claim for Long-Term Disability Benefits (“LTD”), applying for Employment Insurance Benefits (“EI”), advocating for herself and her children and attending activities in the community.
17The respondent relies upon the decision in M.G. v. Unifund Assurance Company, 2025 CanLII 78086 (ON LAT), at paragraph 30, where the evidence confirmed that the applicant was capable of seeking assistance, advocating for herself and accessing resources for assistance. The Tribunal held that the applicant’s excuse was not credible.
18The respondent submits that the applicant’s delay of approximately 15 months is excessive, unjustified, and inconsistent with both the wording and intent of sections 32 and 34 of the Schedule. The respondent argues that based on the decisions in Horvath and K.H., ignorance of the law or misunderstanding of one’s coverage is insufficient to justify non-compliance with statutory timelines. In addition, s. 34 does not relieve an applicant from compliance merely because she misunderstood coverage. Despite the applicant driving her friend’s vehicle, she had her own insurance through the respondent and is deemed to know the applicable period for notifying the respondent of her intention to claim accident benefits or to provide notice as soon as practicable.
19The respondent states that the purpose of the timeline in s. 32(1) of the Schedule is to allow the insurer to conduct contemporaneous assessments, gather medical records, and conduct surveillance if necessary. The respondent argues that a delay of almost 15 months is not minor and has caused significant prejudice from conducting a proper investigation, which weighs heavily against relief. The respondent relies upon the Tribunal decisions in J.V. v. Unifund Assurance Company, 2019 123274 (ON LAT) (“J.V. v. Unifund”) and Abdi v. Travelers Canada, 2021 CanLII 123274 (ON LAT) (“Abdi v. Travelers”).
20The applicant does not dispute that she did not notify the respondent that she had been in an accident on October 3, 2023, until December 31, 2024. The applicant submits that she has provided a reasonable explanation for the delay, which is her complicated pre- and post-accident health coupled with her lack of knowledge of entitlement to benefits. She claims that any prejudice to the respondent is minimal and should be balanced against the hardship she will face if found to be an ineligible claimant.
21The applicant provides a summary of her pre-accident medical history in the year prior to the accident to support that she was physically and emotionally vulnerable at the time of the accident. She submits that as she was not driving her own vehicle at the time of the accident, she did not know to report the accident to her own insurer. The applicant then provides a summary of the medical difficulties she experienced post-accident.
22The applicant submits that unlike the applicant in M.G. v. Unifund, she is not able to advocate for herself as she would like and relies on others for assistance. She relies upon the CNR of Iryna Svetov, nurse practitioner, dated December 14, 2023, which describes the symptoms that hinder her cognitive functions, which make it challenging to absorb information, concentrate, recall and make decisions. She further relies on the CNR of Ms. Svetov dated November 28, 2024, that notes for the first time that she is intending to apply for accident benefits. The CNR states that she “reports she was driving someone else’s car and did not know entitled to submit”.
23The applicant submits that there is no prejudice to the respondent with regard to available medical evidence because the relevant evidence is bountiful, including the CNRs from Mamaway, her Short Term Disability (“STD”) and LTD files, her OHIP Summary and her employment records. The subject matter is distinguishable from the decision in Abdi v. Travelers, which contemplates situations where the relevant evidence is no longer available.
24The applicant relies upon the Court of Appeal decision in Tomec v. Economical Mutual Insurance Co., 2019 ONCA 882, 148 O.R. (3d) 438 (“Tomec”), where the Court set out the overriding principle to be applied in interpreting the Schedule, at para. [42] as follows:
The SABS are remedial and constitute consumer protection legislation. As such, it is to be read in its entire context and in their ordinary sense harmoniously with the scheme of the Act, the object of the Act, and the intention of the legislature. The goal of the legislation is to reduce the economic dislocation and hardship of motor vehicle accident victims and as such, assumes an importance which is both pressing and substantial.
25The applicant submits that Tomec also states at para. 45, that faced with a choice between an interpretation of the statue “that furthers the public policy objectives underlying the SABS and one that undermines it, the only reasonable decision is to side with the former.”
26The applicant also relies upon the Division Court decision in Hussein v. Intact Insurance Company, 2025 ONSC 842 (“Hussein”), where the Court held that at para. [38],
Consumers who have motor vehicle accidents are in a vulnerable position, particularly in the period immediately following the accident and seven days is a very short notice period…The entitlement to damages for motor vehicle accidents in Ontario and the role of the SABS in that regime is not something that is fair to assume the average consumer would be familiar with. Insurance adjusters and agents, on the other hand, can be presumed to know that if one of their insureds has an accident and is injured in that accident, they will want to make a claim for accident benefits.
27The respondent in its reply submissions acknowledges the applicant’s pre-accident medical history but submits that it does not justify the nearly 15-month delay in providing notice. It argues that the applicant was functioning following the subject accident and there are no records to suggest that she was unable to use a computer or phone, or that she otherwise lacked the capacity to make inquiries or notify the respondent in a timely manner. The respondent submits that the applicant possessed the capacity to advocate for herself and to actively pursue benefits and resources, whether by securing appropriate assistance or by drafting and organizing the necessary materials needed independently.
28I find that a reasonable explanation for the delay was provided by the applicant pursuant to s. 34 of the Schedule for the following reasons.
29The parties agree that the applicant did not notify the respondent of her intention to apply for accident benefits within seven days after the circumstances arose that give rise to his entitlement to accident benefits as required by as required by s. 32(1) of the Schedule. Rather, the applicant did not notify the respondent of her intention to apply for accident benefits until December 31, 2024. The issue before me is whether the applicant has provided a “reasonable explanation” for the delay pursuant to s. 34 of the Schedule.
30While both parties have referred me to multiple Tribunal decisions, I am not bound by previous Tribunal decisions. I find that each of the fact scenarios in the decisions relied upon by the parties are unique and can be distinguished from the facts in this matter. I find that a determination of whether a reasonable explanation has been provided requires a case-by-case analysis based on the facts and an analysis of the principles in Horvath and K.H. An 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 limit.
31I find in assessing these principles, consideration must also be given to the principles set out in Tomec with respect to consumer protection, and Hussein where it must be recognized that consumers who have motor vehicle accidents are in a vulnerable position.
32The respondent takes issue with the applicant’s explanation for the delay that she was not aware of her rights or that she had access to accident benefits. However, I accept the applicant’s evidence that this was the true reason why there was a delay in reporting the accident to the respondent. I agree with the applicant that she suffered from significant pre-accident medical conditions and that following the subject accident, her condition deteriorated even further. I further accept the applicant’s evidence that she was not familiar with the accident benefits process and therefore she did not realize until her appointment with her Nurse Practitioner on November 28, 2024, that she had access to accident benefits. I find that based on the applicant’s activities of inquiring, navigating and pursuing her other claims for LTD benefits and EI benefits, that had she known of her entitlement to accident benefits, she would have submitted an Application for Accident Benefits. While I agree that the applicant had the capacity to seek information and take timely action, albeit with assistance from others, it was truly her ignorance of her rights that caused the delay.
33While I agree that ignorance of the law alone is not a reasonable explanation, the test of “reasonable explanation” is both a subjective and objective test that should take into account both the personal characteristics and the “reasonable person” standard. While the respondent argues that the applicant is deemed to know the applicable period for notifying the respondent of her intention to claim accident benefits or to provide notice as soon as practicable a sophisticated party, it is clear that the applicant is an unsophisticated person who struggles psychologically and cognitively. There is also no evidence that the applicant was previously involved in a motor vehicle accident and was aware of the process involved.
34I do agree that the respondent has been prejudiced by the delay because it was not aware of the applicant’s intention to seek accident benefits and could not assess her. While the delay has prevented the respondent from assessing the applicant’s medical records and sending her for assessments, the applicant’s voluminous medical records have been provided to the respondent, and her disability records would be provided upon request. However, I find that in contrast, the applicant will face significant hardship if she is prevented from proceeding with her Application for Accident Benefits.
35Without addressing the merits of the applicant’s medical records, in my view, the hardship to the applicant if she is prevented from proceeding with her Application for Accident Benefits, would be far greater than any prejudice faced by the respondent. On balance, I find it would be equitable to relieve against the consequences of the applicant’s non-compliance with s. 32(1) of the Schedule because I find that the applicant has provided a reasonable explanation for the delay under s. 34 of the Schedule. I find that the applicant has met her onus and may proceed with her Application for Accident Benefits.
ORDER
36For the reasons outlined above, I find that the applicant is not barred from proceeding to a hearing.
Released: April 22, 2026
Melanie Malach
Adjudicator