Citation: Sanjeev v. Definity Insurance Company, 2026 ONLAT 24-008953/AABS

Licence Appeal Tribunal File Number: 24-008953/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:

Sanjeev Sanjeev

Applicant

and

Definity Insurance Company

Respondent

DECISION

ADJUDICATOR:

Ulana Pahuta

APPEARANCES:

For the Applicant:

Neha Kohli, Paralegal

For the Respondent:

Matthew Murphy, Counsel

HEARD:

By way of written submissions

OVERVIEW

1Sanjeev Sanjeev, the applicant, was involved in an automobile accident on November 20, 2022, 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, Definity Insurance Company, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.

2In a case conference held on October 29, 2024, the substantive issues in dispute were set to be heard at this scheduled written hearing. A separate preliminary issue hearing was also scheduled to be heard prior to this substantive written hearing, to address the preliminary issue in dispute.

3However, by way of a procedural order dated November 22, 2024, the Tribunal determined that the preliminary issue would not be heard by way of a separate preliminary issue hearing. Rather, the preliminary issue was ordered to be heard together with the substantive issues in dispute. Accordingly, at this written hearing I will address the preliminary issue in dispute, prior to addressing the substantive issues in dispute.

PRELIMINARY ISSUE

4The preliminary issue to be decided is:

1. Is the applicant barred from proceeding to a hearing as they 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?

SUBSTANTIVE ISSUES

5The substantive issues in dispute are:

1. Are the applicant’s injuries predominantly minor as defined in s. 3 of the Schedule and therefore subject to treatment within the $3,500.00 Minor Injury Guideline limit?

2. Is the applicant entitled to the assessments or treatments proposed by Complete Rehab Centre, as follows:

i. $2,530.00 for a psychological assessment, in a treatment plan dated December 31, 2023; and

ii. $2,914.70 for an orthopedic assessment, in a treatment plan submitted October 4, 2023?

3. Is the applicant entitled to $3,610.50 for psychological services, submitted January 19, 2024?

4. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?

5. Is the applicant entitled to interest on any overdue payment of benefits?

RESULT

6I find that the applicant is statute-barred, pursuant to s. 55(1) of the Schedule, from proceeding to a hearing on the substantive issues in dispute.

7The application is dismissed.

ANALYSIS

PRELIMINARY ISSUE

Law

8Section 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.

9Once 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 benefits and information on the election relating to the specified benefits, if applicable (s. 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.

10Section 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 more recently reiterated in K.H. vs Northbridge, 2019 CanLII 101613 (ON LAT). 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.

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.

11Pursuant to section 55(1)1, 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 applied for the benefit within the times set out in the Schedule.

Background and Parties’ Positions

12The applicant was involved in a motor vehicle accident on November 20, 2022. On September 12, 2023, the applicant submitted a Treatment Confirmation Form (OCF-23) to the respondent, and on September 28, 2023 he provided an Application for Accident Benefits (OCF-1) to the respondent.

13By way of letter dated October 4, 2023, the respondent informed the applicant that it had first been notified of the accident on September 12, 2023, when it had received the OCF-23. The respondent noted the applicant’s late submission of his intention to claim accident benefits, and requested further information, including the applicant’s explanation for the delay, and a Statutory Declaration. In a subsequent letter dated July 16, 2024, the respondent denied the applicant’s claim for accident benefits, citing the applicant’s failure to provide a reasonable explanation for the delay.

14The respondent argues that the applicant failed to comply with the notice provision in s. 32(1) of the Schedule, and as such, should be barred pursuant to s. 55(1) from proceeding with the substantive issues in dispute. It further submits that the only explanation the applicant provided for the delay was in his statement to the insurer, when he stated that he thought his injuries would improve. The respondent cites the Tribunal decision Darkov v Travelers Insurance Company of Canada, 2023 CanLII 40146 (ONLAT) to argue that such an explanation has not been accepted as credible by the Tribunal.

15The applicant did not address the issue of s. 32(1) non-compliance in his submissions for this hearing. In his initial hearing submissions, filed on June 18, 2025, the applicant provided submissions only on the substantive issues in dispute, but did not provide submissions on the preliminary issue. The applicant also did not provide reply submissions to address the respondent’s responding submissions.

Was the applicant compliant with s. 32(1) or did he have a reasonable explanation for the delay?

16I find that the applicant was non-compliant with s. 32(1) of the Schedule, and did not provide a reasonable explanation for the delay.

17The applicant did not dispute that he first notified the respondent of his intention to pursue accident benefits on September 12, 2023, almost 10 months after the accident. I find that this is well-outside the time limit stipulated in s. 32(1) of the Schedule.

18The applicant further has not provided any submissions, either in his initial written hearing submissions or by way of reply submissions, to address the preliminary issue or to provide a reasonable explanation for the delay, as required by s. 34 of the Schedule. Without any submissions from the applicant on this issue, I find that the applicant is non-compliant with s. 32(1) of the Schedule.

19Accordingly, the applicant is barred from proceeding to a hearing with the substantive issues in dispute, for failing to notify the respondent of the circumstances giving rise to a claim for benefits, in breach of section 32(1). He has not provided a reasonable explanation for the delay pursuant to section 34. Therefore, in accordance with section 55(1)1, I find that the applicant is barred from proceeding with his application.

ORDER

20The applicant is barred from proceeding with the substantive issues in dispute pursuant to section 55(1) of the Schedule, for failure to comply with the time limits set out in section 32(1).

21The application is dismissed.