Licence Appeal Tribunal File Number: 25-010076/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:
Grant Koropatnicki
Applicant
and
Northbridge General Insurance Company
Respondent
PRELIMINARY ISSUE DECISION AND ORDER
ADJUDICATOR:
Trina Morissette, Vice-Chair
APPEARANCES:
For the Applicant:
Taran Hoogsteen, Counsel
For the Respondent:
Riley Groskopf, Counsel
HEARD: In writing
OVERVIEW
1Grant Koropatnicki, the applicant, was involved in an automobile accident on February 25, 2022 and sought benefits from Northbridge General Insurance Company, 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 ISSUES IN DISPUTE
2The preliminary issue to be determined is whether the applicant is barred from proceeding with his claim for benefits because he failed to submit his application for benefits (OCF-1) within the time prescribed in the Schedule?
RESULT
3The applicant provided a reasonable explanation for his delay in submitting his OCF-1 and is not barred from proceeding with his application.
4The application shall proceed to a hearing on the substantive issues as previously scheduled.
ANALYSIS
5Section 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.
6Once 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.
7Section 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 (“Horvath”) 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.
8Pursuant to the information contained in the OCF-1, on February 25, 2022, the applicant was driving with his wife and daughter when they were struck by another vehicle and pushed off the road into a guardrail. The applicant submits he sustained a spinal injury requiring surgery, as well as injuries to his neck, back, left leg, foot, and hand. He also complains of chronic pain, nerve damage, numbness and tingling. This matter is complicated by the fact that the applicant has a history of back issues and related pain, including a back surgery one week prior to the subject accident, on February 18, 2022.
9The parties do not dispute that notification of the accident was provided as required by section 32(1). The parties also do not dispute that the applicant submitted his completed application (OCF-1) to the respondent on March 19, 2025, more than three years post-accident. The issue before me is whether the applicant provided a reasonable explanation for the delay in submitting his application.
10Based on the evidence submitted and the parties’ submissions, the facts in this matter include the following.
11On March 10, 2022, the respondent’s adjuster spoke with both the applicant and his wife (in separate telephone calls) and advised she would be sending them each an accident benefits package with further information by email.
12On March 11, 2022, accident benefits packages were separately emailed to each the applicant, his wife and his daughter. This communication included an email message advising of the attached accident benefits package, the name and contact information of the respondent’s adjuster, and notice that additional forms would be forwarded shortly thereafter. The cover letter included a notice that should the applicant wish to make a claim for accident benefits, the Application for Accident Benefits (OCF-1) must be returned “within 30 days after receiving this package. Your benefits may be affected if you do not return it within 30 days of receipt.” [emphasis in original]
13Within days of receiving the package, the applicant’s wife contacted the respondent’s adjuster with questions and for further information regarding her accident benefits. Although there was email correspondence between the respondent’s adjuster and the applicant regarding the property damage part of the claim, the applicant did not make any inquiries regarding his accident benefits.
14On May 2, 2022, the applicant’s wife advised the adjuster that the applicant did not receive his accident benefits package sent to him by email. She requested that it be resent “as he is beginning physiotherapy and his symptoms are not getting any better unfortunately.” The adjuster confirmed that the initial package was sent to his email on March 11, 2022, she provided the email address on file for confirmation, and advised that the package would be resent. On May 3, 2022, the package was resent to both the applicant’s email as well as to his wife’s email.
15On or about May 4, 2022, the applicant’s wife submitted an OCF-3. Through an Explanation of Benefits, the respondent advised the applicant’s wife that her request was denied as she had yet to submit her completed OCF-1. In response, a completed OCF-1 on behalf of the applicant’s wife and a separate OCF-1 on behalf of his daughter were submitted to the respondent the following day. No OCF-1 was submitted on behalf of the applicant.
16By email dated July 12, 2022, the respondent’s adjuster contacted the applicant’s wife to “touch base to see how you, [the applicant] and [the applicant’s daughter] are doing since the last time we spoke. If there is anything you need assistance with please let me know.” In a response a month later (dated August 12, 2022), the applicant’s wife provided an update on her and her daughter. Regarding the applicant, she stated: “he has been stubborn and avoiding getting help for his neck and back pain. I believe that I have talked him into going in for some therapy.”
17Approximately two years later, on May 28, 2024, the respondent advised the applicant by correspondence that his file was being closed. The correspondence states, in part:
As per previous correspondence, you are not interested in pursuing your accident benefits claims. We are closing your file. Please be reassured that closure of your file does not limit your rights under the [Schedule] or preclude us from reopening your file within five years from the date of the accident should it become necessary.
18Approximately eight months later, on or about January 17, 2025, the applicant retained legal representation.
19On January 28, 2025, the applicant submitted an OCF-18 in the amount of $2,348.72 for case management services. The treatment plan was denied on February 11, 2025. In its reasons, the respondent states:
Please note at this stage almost 3 years post date of loss, we have not received an Application for Accident Benefits from you. You have not attended treatment and we have had no requests for treatment until this plan. Please submit a completed [OCF-1] in order for treatment requests to be considered. A blank copy has been enclosed for your convenience. Further, once the [OCF-1] is received we will be arranging an [EUO] regarding your injuries and the delay in treatment. Further details will follow(sic) under separate cover at a later date.
20Subsequent treatment plans were submitted by the applicant on March 12, 2025 and March 14, 2025 and both were denied on the basis that an OCF-1 had yet to be submitted. Blank OCF-1 forms were provided with each denial.
21On March 19, 2025, the applicant submitted his completed OCF-1, being 1,104 days (three years and nine days) after the first accident benefits package was provided, and 1,051 days after the second accident benefits package was sent.
The applicant has a reasonable explanation for his delay
22The applicant submits the following explanations for his delay:
i. The respondent did not meet its obligations under section 32(2) of the Schedule or Hussein v. Intact Insurance Company, 2025 ONSC 842 (“Hussein”) and therefore the 30-day timeline of section 32(5) was not triggered;
ii. He relied on the respondent’s conduct to his detriment and that, pursuant to section 131 of the Insurance Act, R.S.O. 1990, c. I.8, (“the Act”) he should not be held to the 30-day deadline to submit his application;
iii. The respondent reset the 30-day timeline in February 2025: and
iv. The respondent did not provide evidence that it advised him and his wife that by not submitting the OCF-1 within 30 days could jeopardize his claim.
Section 32(2) and Hussein
23As noted above, once the applicant notified the respondent of the accident and his intention to apply for statutory accident benefits (section 32(1)), the respondent had a statutory obligation to provide him with the appropriate OCF-1 forms, a written explanation of the benefits available, and information to assist him in applying for benefits including any applicable specified benefits. Pursuant to 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.
24The applicant submits that the accident benefits process was explained to his wife but, as evidenced by the log notes, it was never explained to him personally. He concedes that the respondent provided the accident benefits package but, relying on Hussein and Amankwatia v. TTC Insurance Company, 2025 CanLII 102181 (ON LAT), the respondent fell short of its obligation to inform and assist him in applying for benefits. He argues that when the respondent did not receive a response to its accident benefits package, it never attempted to contact him directly to assess his intentions, or to ensure that he was aware there was a timeline.
25The respondent submits that it provided the applicant, his wife and his daughter with the required accident benefits package and was advised by the applicant that his wife was handling the accident benefits part of their claim. The respondent was in constant contact with his wife, responded to all her requests for information and remained active in her pursuit of benefits. In August 2022, the applicant’s wife advised the respondent that the applicant had not yet submitted his OCF-1 because he was being stubborn and was avoiding getting help for his neck and back pain. The respondent argues that it is clear by the communications in this matter that the delay was not caused by a lack of understanding of the process, but rather by the applicant’s own decision not to pursue treatment or benefits.
26I agree with the respondent. Not only was the accident benefits package provided to the applicant on more than one occasion, I find that the respondent’s adjuster in this matter was responsive to all of the applicant’s wife’s information requests. The adjuster was diligent in providing the applicant’s wife with the information sought, and she was not only reactive but also proactive in reaching out, as evidenced by her email to the applicant’s wife of July 12, 2022. I find the applicant’s argument that the respondent had a duty to reach out directly to the applicant and inquire why he had yet to submit his application is unreasonable, particularly since he made it clear to the respondent that his wife would be dealing with their accident benefits claims. As such, with respect to its obligations pursuant to section 32(2) and Hussein, I find the respondent’s adjuster met and exceeded all statutory obligations and expectations.
The remaining explanations for the delay
27In my view, the applicant’s remaining explanations for his delay – his reliance on section 131 of the Act, his allegation that the timeline was reset by the respondent, and his argument that the respondent lacked evidence that it warned the applicant of the consequences for not meeting the 30-day timeline – all stem from the same main issue. This main issue centres on the information provided by the respondent which gave the applicant the impression that, so long as the OCF-1 was submitted at some point, the applicant’s claims for benefits would be considered.
28First, I am not persuaded by the applicant’s reliance on section 131(1) (b) of the Act or by his argument that estoppel should apply in these circumstances. I acknowledge that the applicant relies on Akinyimide v. Economical Mutual Insurance Company, 2023 ONSC 5272 where the Divisional Court found the Tribunal has jurisdiction to consider and apply equitable remedies such as estoppel, but the applicant’s submissions fail to set out how the facts in this matter are appropriate to do so. The Supreme Court of Canada in Ryan v. Moore, 2005 SCC 38, [2005] 2 SCR 53 (“Ryan”) set out the legal test to determine whether estoppel should apply but the applicant did not reference Ryan, its legal test, or explain how the legal test is applicable to the facts herein. As such, I find that the applicant has not satisfied me that section 131 and/or the doctrine of estoppel apply.
29Secondly, the applicant submits that the respondent reset the 30-day timeline of section 32(5) when it sent a new request to complete an OCF-1 as an act of “good faith” on February 11, 2025. I disagree and find that resending the package or an OCF-1 form does not automatically reset the 30-day timeline. In my view, to find otherwise would allow for insureds to consistently allege non-receipt of the accident benefits package in an attempt to circumvent the 30-day timeframe. Here, by advising the applicant that the treatment plan submitted was denied because he had not yet submitted his OCF-1, and providing an OCF-1 form with the denial, does not automatically reset the timeline.
30Finally, the thrust of the applicant’s remaining explanation is that the respondent never explained that failing to submit the OCF-1 within the 30-day timeframe could jeopardize his claim for benefits or disentitle him from a claim. Rather, the applicant argues that at every stage, the respondent gave him the impression that as soon as an OCF-1 was received, it would consider his claims. The applicant argues that the language provided in its communications misled him and he relied on this wrongful impression to his detriment.
31The respondent submits that assistance and information was available and provided. It also submits that the direction and guidance provided to the applicant and the members of his family was appropriate and sufficient. It argues that as his family members were able to commence and pursue claims from the same accident, it argues that the applicant made his own choice not to apply for benefits and his ignorance of the process is not a reasonable explanation. The applicant was provided with all information necessary to commence his accident benefits claim, and, without a reasonable explanation, he failed to submit his application for benefits for over three years.
32From the perspective of an unsophisticated person, I accept that the information provided to the applicant regarding the requirement to submit his application within 30 days as per section 32(5), and more specifically, the consequences for failing for do so, were not clearly communicated by the respondent. I find that the language provided by the respondent does not clearly convey the consequences should the applicant delay the submission of his OCF-1 and could have mislead the applicant to his detriment.
33The respondent’s cover letter accompanying the accident benefits package states that “[y]our benefits may be affected if you do not return [the OCF-1] within 30 days of receipt.” In my view, this does not convey the reality or the urgency that failing to submit a completed application within the 30-day timeline can jeopardize and/or preclude the applicant from any potential accident benefits claims. From an unsophisticated person’s perspective, the use of “[y]our benefits may be affected” gives the impression that the respondent will consider all factors when the time comes. When communicating to an insured, an insurer must use straightforward and clear language directed towards an unsophisticated person so that the insured can make a well-informed decision. I find that the respondent fell short here.
34The respondent submits that a consideration of a claim is not a guarantee that benefits will be paid and the language provided cannot be reasonably constructed to mean that. I agree with this premise, however, for an insured who has no or little knowledge of the Schedule, the information provided must be straightforward and clear and here, I find the respondent did not clearly convey the importance of filing his OCF-1 within 30 days or the consequences for failing to do so. This is supported by the fact that the applicant’s wife did not submit her completed OCF-1 until May 5, 2022, which was over the 30-day timeline. The respondent accepted her application and her OCF-3 and other claims were considered nonetheless, reinforcing the belief that even if the OCF-1 if submitted after 30 days, the applicant’s claims might still be considered.
35In the respondent’s “closing letter” provided to the applicant in May 2024, the respondent explained that “[p]lease be reassured that closure of your file does not limit your rights under the [Schedule] or preclude us from reopening your file within five years from the date of the accident should it become necessary.” In my view, this language leaves the applicant with the impression that the door remains open for future consideration of a request for benefits and does not point to the consequences of the delay without a reasonable explanation which is what the Schedule requires as evidence by the preliminary issue raised by the respondent.
36There is no evidence before me that the applicant sought treatment in the period of time prior to retaining counsel despite his wife’s comments to the respondent’s adjuster that he would, or that he should, but the question before me is whether the applicant presented a reasonable explanation for not submitting his OCF-1 within 30 days. Based on my analysis above, I find that the language provided by the respondent led the applicant to believe that if he did not submit it within the timeline, a decision on whether he would be entitled to his claims would be made at the moment his OCF-1 was submitted.
37An 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.
38The respondent submits that the objectively long delay (over three years) has created real prejudice in its ability to properly administer the claim. With the applicant’s history of back issues and related pain, including surgery a week prior to the subject accident, the respondent has a great challenge in determining causation and whether any of the applicant’s surgeries (and rehabilitation following the surgeries) were the result of the subject accident, or were pre-existing. The respondent argues that it has been stripped by the inaction of the applicant of the ability to obtain necessary information such as contemporaneous medical assessments and/or make appropriate rehabilitation recommendations.
39The applicant submits that the delay is minimum and would cause no prejudice to the respondent. Any hardship to the applicant in not being able to pursue his claim would far outweigh any prejudice to the respondent.
40I acknowledge the predicament the respondent finds itself in and I agree that not being able to assess the applicant in the three years following the accident, especially with his pre-existing back issues, has caused it prejudice. However, the prejudice sustained by the respondent, in my view, is caused by the respondent’s own actions – the language it used in conveying the applicant’s obligations pursuant to section 32(5).
41For these reasons, I find that the applicant has provided a reasonable explanation for his delay in submitting his OCF-1 and the applicant may proceed with his application. In my view, the balance of the matter favours the applicant to proceed with his application as he will still have the substantive burden of proving his entitlement to the benefits he claims.
ORDER
42For the above reasons, I find:
i. The applicant provided a reasonable explanation for his delay in submitting this OCF-1 and is not barred from proceeding with his application.
ii. The application shall proceed to a hearing on the substantive issues as previously scheduled.
Released: April 27, 2026
Trina Morissette
Vice-Chair