Licence Appeal Tribunal File Number: 25-010417/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:
Matthew Makosz
Applicant
and
Belair Insurance Company Inc.
Respondent
PRELIMINARY ISSUE DECISION AND ORDER
ADJUDICATOR:
Trina Morissette, Vice-Chair
APPEARANCES:
For the Applicant:
Self-represented
For the Respondent:
Laura Meschino, Counsel
HEARD:
In writing
OVERVIEW
1Matthew Makosz, the applicant, was involved in an automobile accident on September 8, 2021, and sought benefits from Belair Insurance Company Inc., 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 Case Conference Report and Order (“CCRO”) dated December 12, 2025, identified the following preliminary issues:
i. Is the applicant barred from proceeding to a hearing as he 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?
ii. Is the applicant barred from proceeding with his claim for benefits as he failed to submit the application for benefits (OCF-1) within the time prescribed in the Schedule?
iii. Is the applicant barred from proceeding to a hearing for all benefits in this application because he failed to dispute the denials within the two-year limitation period?
3In its submissions, the respondent seeks to add the following preliminary issue:
i. In the alternative, is the applicant barred from proceeding to a hearing of his income replacement benefit (“IRB”) claim because he failed to submit a completed Disability Certificate (OCF-3) within 104 weeks of the accident?
4The applicant, a self-represented party, did not file submissions on these preliminary issues.
5I find that the preliminary issue the respondent seeks to add is not a true preliminary issue. Rather, it is a reason for denial that the respondent can argue at the substantive issues hearing should the matter proceed. In any event, this preliminary issue was not raised at the case conference, was not identified as a preliminary issue in the CCRO, and there is no evidence that the respondent raised this preliminary issue prior to the service and filing of its submissions for this preliminary issue hearing. Pursuant to Rule 20.4 of the Licence Appeal Tribunal Rules, 2023, any preliminary issue a party intends to raise must be included in their case conference summary.
6As the preliminary issue the respondent seeks to add is not a true preliminary issue, and as the applicant was not provided with proper notice of the additional preliminary issue and was not provided with appropriate time to consider and respond to the issue, on the basis of procedural fairness and Rule 20.4, it will not be considered within the context of this Preliminary Issue Decision.
RESULT
7The applicant properly notified the respondent of the accident within the timeframe set out in the Schedule.
8The applicant did not submit his application to the respondent within the timeframe of the Schedule and has not provided a reasonable explanation for his delay. The applicant is barred by section 55(1) from proceeding with his application before the Tribunal.
9The respondent did not meet its onus to show the applicant failed to dispute the denials within the two-year limitation period.
ANALYSIS
10Section 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.
11Once 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.
12Section 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.
The applicant notified the respondent of the accident pursuant to the Schedule
13The applicant provided a description of the accident to the respondent on September 13 and 14, 2021, as evidence by the adjusters’ log notes. The applicant stated he was driving through an intersection when another vehicle, turning left, struck the front driver’s side of his vehicle. Emergency personnel attended the scene. The applicant complains of whiplash, neck issues and back issues.
14The respondent concedes that the applicant notified it of the accident within days of the incident.
15As there is not dispute, I find that the applicant notified the respondent of the accident pursuant to section 32(1) of the Schedule.
The applicant did not submit his application within 30 days and has not provided a reasonable explanation for the delay
16As previously noted, the applicant did not file submissions on this preliminary issue hearing.
17The respondent submits that despite repeated communications between the applicant and the respondent at the outset of the accident notification, the applicant did not submit his OCF-1 until June 2, 2025, over three years and eight months after the accident (1,363 days). The respondent further submits that there is no evidence of physical, psychological, or other intervening life circumstances that would have hindered his ability to complete and submit his OCF-1 for over three and a half years. As the applicant has not discharged his onus of providing a reasonable explanation for the delay, the respondent submits that the applicant should be barred from proceeding with his application.
18I have reviewed the evidence submitted by the respondent which includes the adjusters’ log notes in this matter.
19On September 20, 2021, the respondent provided an accident benefits package to the applicant. The package includes a step-by-step guide on how to apply for accident benefits, information regarding the various benefits the applicant may be entitled to, copies of the various forms, and notice that the application (OCF-1) must be returned within 30 days after receiving the package.
20Between September 23, 2021 and November 1, 2021, there were numerous attempts by the applicant to speak to a representative of the respondent by telephone. Likewise, there were numerous attempts by the respondent to contact the applicant by telephone. The calls to the applicant went unanswered and there was no opportunity to leave a voicemail message. Ultimately, the parties were able to connect, and all discussions they had were in relation to the property damage portion of the applicant’s claim. Aside from the initial discussions on September 13-14, 2021, injuries and accident benefits were not discussed.
21In a letter dated October 25, 2021 – in the midst of the applicant’s discussions with the respondent regarding his property damage claim – the applicant is advised that he had not provided his application within 30 days of receipt of the accident benefits package and his file would be closed without further notice. The applicant was encouraged to contact the respondent should he require assistance in completing his application.
22On November 5, 2021, the applicant’s accident benefits file was closed.
23On January 20, 2022, the applicant contacted the respondent and requested that his accident benefits file be reopened. The log notes indicate he “stated he wasn’t able to go for [treatment] then but now he can”. The applicant confirmed he still had the initial accident benefits package provided, nonetheless, the respondent resent an OCF-1 form and advised him to complete and submit his application.
24Two years later on January 24, 2024, having not provided a completed OCF-1, the applicant contacted the respondent by telephone requesting confirmation that his file was closed. The respondent confirmed the applicant’s accident benefits file was closed.
25Between May 3, 2025 and May 5, 2025, the applicant contacted the respondent and requested that his file be “renegotiated”. The respondent provided him with another OCF-1 form by email which he was advised to complete and submit. Requests were also made for medical documentation. In an email to the respondent, the applicant explained:
The accident caused his diagnosed schizophrenia. The link between the diagnosis and the accident was not made at that time because he was “too muscular and healthy”. He has since spent time in and out of psychiatric facilities (court ordered) and is unable to work.
26Following this call, the applicant requested assistance in the completion of the OCF-1. The respondent provided additional information by email and offered to speak to the applicant by telephone.
27On June 2, 2025, the applicant submitted his application to the respondent.
28Based on the information above, the applicant provided two explanations for his delay in submitting his OCF-1 between September 20, 2021 (when the accident benefits package was first provided) and June 2, 2025 (when the OCF-1 was submitted):
i. The applicant was “not able” to go for treatment after the accident but advised that after January 2022, he could; and
ii. The accident caused his schizophrenia and he had been court ordered to be placed in psychiatric facilities.
29On July 16, 2025, the respondent denied the applicant’s claim for accident benefits. The respondent provided three reasons for its denial: (1) the incident of September 8, 2021 was not an “accident” as defined in the Schedule; (2) the applicant failed to submit his completed application within the 30-day timeline of section 32(5) of the Schedule; and (3) “[t]he compelling medical evidence on file received in our office on June 16, 2025 and spanning the period of September 18, 2018 to February 14, 2025 does not support the assertion that the use and operation of your automobile in the incident dated September 8, 2021 directly caused your ongoing medical impairments.”
30I find that the applicant’s explanation that he was not able to go for treatment until January 2022 is not credible nor worthy of belief as it does not explain why he did not complete and submit his OCF-1 within the 30-day timeline. The applicant spoke to the respondent on numerous occasions about the property damage aspect of his claim but did not seek any assistance with his accident benefits until May 2025. I note that following notification of the accident in September 2021, the respondent had also assisted the applicant by recommending a health practitioner (CBI Health) to assist him with the completion of the forms. The applicant failed to attend two appointments with CBI Health and advised he had found a health practitioner closer to his home. I therefore do not find this explanation reasonable.
31Regarding the applicant’s second explanation (i.e., the accident caused his schizophrenia), without any medical documentation, or other documentation such as Form 1s or court orders, I cannot find that the applicant’s explanation is credible or believable. There is no evidence before me, aside from what the applicant reported to the respondent in its log notes, that support the applicant’s mental health complaints or that support he was retained in any psychological institutions for any amount of time. For these reasons, I find the applicant has not provided a reasonable explanation for his delay in submitting his OCF-1.
32An 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 respondent points to the significant delay in submitting his application. I agree that the delay is significant and has hindered the respondent’s ability to investigate and assess the applicant’s alleged impairments.
33Taking into account the principles of K.H., I find that the applicant has not satisfied his onus of providing a reasonable explanation for his delay in submitting his OCF-1, and the delay of over three years in 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 which I find outweighs any hardship to the applicant.
Section 55
34Pursuant 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.
35As outlined above, I find that the applicant did not submit an application for benefits within the timelines 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.
The respondent failed to meet its onus to show the denials were not disputed within the two-year limitation period
36In its submissions, the respondent does not identify nor does it provide submissions on its claim that the applicant failed to dispute the denials within the two-year limitation period. With no submissions, I find the respondent has not met its onus to show the applicant failed to dispute his denials within the two-year limitation period at section 56 of the Schedule.
ORDER
37For the reasons stated above, I find:
i. The applicant properly notified the respondent of the accident within the timeline set out in the Schedule.
ii. The applicant did not submit his application to the respondent within the timeframe of the Schedule and has not provided a reasonable explanation for his delay. The applicant is barred by section 55(1) from proceeding with his application before the Tribunal.
iii. The respondent did not meet its onus to show the applicant failed to dispute the denials within the two-year limitation period.
iv. The application is dismissed.
Released: May 6, 2026
Trina Morissette
Vice-Chair