An obstacle defense is possibly the most powerful defense in existence. Its application completely extinguishes someone’s declares, essentially on a technicality, no matter whether such declare have merit.
The limitation period for coincidence benefits claims is defined in section 56 of the Statutory Accident Benefits Schedule. It states that arbitration in admiration of a benefit “will begin inside two years after the insurer refuses to pay the amount claimed.”1 This drawback period changed into not changed within the 2010 or 2016 amendments and ought to follow all open claims. Thus, before April 1, 2016, this hassle period could be extended under the circumstance that events commenced mediation court cases under s. 280 of the Insurance Act within the years of the denial. However, that extension additionally no longer applies to current claims given that we are now more than three years publish the April 2016 amendments.
The Supreme Court of Canada held in Smith v Co-operators General Insurance Co. that there are necessities for an insurer to trigger the two-year challenge period
(a) There needs to be an unequivocal refusal, with reasons, for the insurer’s dedication. Three A “clear and unequivocal” refusal has been interpreted as meaning “unambiguous and not liable to misunderstanding.” Four
(b)There needs to be a good enough clarification, in lay terms, of the proper of the insured individual to dispute the refusal and the process for doing so. Five
The above prison check has been diagnosed and followed continually by adjudicators and is a settled legal precept.6
It is essential to word that an insurer may be stopped from counting on a quandary duration defense if a claimant fairly is predicated on the insurer’s conduct after the refusal to their detriment.7For example, if an insurer’s otherwise unambiguous denial is eventually made ambiguous (e.G. With the aid of a letter, verbal exchange, or another form of conduct that could propose to a fairly minded claimant that the insurer might not be depending upon the sooner denial), then this may invalidate the dilemma length. This happens most usually happens while an insurer is presented with new statistics (such as clinical notes and information or an impartial clinical file) and reconsiders its advance decision. If the insurer’s reconsideration misled the claimant as to the reputation of their declare for benefits or indicates that the insurer changed its function in admire to the benefit, eight or shows that the time restriction for arbitration turned into waived or brought on the Applicant into a fake feeling of safety about the walking of the drawback period,9 then the insurer may be prevented from relying upon a dilemma duration defense.
That stated, the fact that an insurer reconsiders its in advance selection does not mechanically restart the drawback period. The tribunal in Zeppieri v Royal Insurance Company of Canada recounted that an insurer is obliged to adjust claims in a proper manner, which necessitates reconsidering a terminated gain once it is supplied with new facts (in preference to ignoring the new facts in favor of blindly relying upon the earlier denial). Arbitrator Naylor in Zeppieri held that to indicate this reconsideration would restart a predicament period could efficiently render the two-year issue period meaningless. This case has been followed in subsequent cases.10
If a letter of refusal includes unequivocal language, and with that letter are enclosures, which imply each dispute decision method and the dispute resolution process, then the dispute period might be triggered. For example, in 17-006863 v Aviva General Insurance Company, Aviva dispatched the insured a letter of refusal, which outlined the reasons why the claimant changed into not eligible for Income Replacement Benefits. After giving all the reasons, the letter stated: “Based on the above-stated statistics, you no longer qualify for Income Replacement Benefit.” Aviva enclosed with the letter a document that supplied a little-by-little guide to disputing the insurer’s choice. This letter additionally included a clear warning approximately the two-12 months’ quandary. This is a legitimate trigger for the predicament date11. The Ontario Licence Appeal Tribunal (“the Tribunal”) made clear that even if there may be an invitation for the claimant to submit further documentation, this doesn’t override a valid refusal and the deadline remains induced.
An insurer mistakenly identifying the suitable termination date in the next correspondence to a claimant will not save an insurer from depending upon a dilemma period defense. Specifically, if an insurer terminates an advantage on a specific date and then, in subsequent correspondence, mistakenly references a later date as being the date of termination, such a mistake will not invalidate the refusal furnished the claimant understood the termination was not later than the wrong date.12 In other words, the mistake ought to be such that an inexpensive individual could be pressured about whether or not a difficulty period is running or has expired.
To make certain the hindrance period is induced after a denial, an insurer has to explicitly nation that coverage is denied, refused, terminated, and/or stopped (as honestly declaring that coverage or advantage is “unavailable” is ambiguous). Further, submitting clean software after a valid refusal will no longer restart the trouble length as long as the insurer is predicated upon the earlier denial as the premise for denying the fresh utility. Finally, suspending blessings is not considered a valid refusal (as a “suspension” is considered transient while a “denial” is considered clean and unambiguous).
In sixteen-000216 v Aviva Insurance Company Canada, the insurer sent the claimant a refusal letter that said: “You no longer qualify for the Attendant Care gain as there may be no insurance for this below the Minor Injury Guideline.” In the identical letter, Aviva had denied insurance of other advantages via declaring “Not Eligible/Stoppage of Benefit.” thirteen The Tribunal held that advising a claimant that they do now not qualify for a advantage because there is “no insurance” is not similar to refusing to pay a benefit that has been claimed. The Tribunal reasoned that this changed into an invalid refusal. Although the letter said what recourse the claimant had if the benefits were denied with the phrase “Not Eligible/Stoppage of Benefit,” it did not imply what recourse the claimant had while the insurer said, “coverage now not available.” Therefore, they located this to be language that no longer fit the Smith criteria of being unequivocal. This was not a right refusal, and the difficulty period no longer occurred.
