The Importance of Attaching Dispute Resolution Forms to Denial Letters

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An injured motorist has lost an appeal against his insurer, which denied him benefits for seven years before it launched its legal challenge against the decision. A notable aspect of the case was whether the claimant had received a dispute resolution form when she was first informed that her benefits would be cut.

The courts essentially dismissed the plaintiff’s appeal for statute of limitations, noting that it was launched more than three years after a mediation that resulted in her claim being dismissed.

TD didn’t seem in danger of losing the case. Even so, the Ontario Court of Appeal decision noted some initial confusion as to when the insurer denied benefits and whether the claimant was advised of her appeal rights at that time. .

Ummugulsum Yatar was injured in a car accident on February 7, 2010. At the time, she was insured under a motor vehicle liability insurance policy issued by TD Insurance.

She filed a claim for accident benefits with TD Insurance on February 22, 2010. She elected to claim income replacement benefits (IRB), as well as housekeeping and home maintenance benefits.

TD initially paid benefits. But on January 7, 2011, he wrote to Yatar and said that the payment of IRBs, housekeeping and home maintenance benefits had been stopped as of January 4, 2011, because he had not received disability certificate duly completed within the deadline requested in December. Letter of 8 2010.

TD informed Yatar that “no benefits are payable for the period after the date shown and before the day the insurer receives the completed disability certificate.” He also told her that she had to appear for an examination by his chosen assessors at the times and places indicated in an attached notice of examination.

In January 2011, Yatar reported for two insurer medical exams, one with a psychologist and the other with a physiatrist, to determine her eligibility for IRBs, housekeeping benefits, and health benefits. home maintenance.

On February 16, 2011, TD Insurance denied Yatar’s claim for housekeeping and home maintenance benefits based on the exam results. In the same letter, TD advised Yatar that she was eligible for PRRs and would continue to monitor her psychological treatment and rehabilitation to assess her continued entitlement to this benefit.

On September 6, 2011, Yatar presented herself for a medical examination by a third insurer to address her continued entitlement to IRBs. Approximately two weeks later, TD Insurance wrote to Yatar denying its IRB request and informing it that its IRB payments would cease effective September 28, 2011.

A court adjudicator observed that dispute resolution forms were not attached to correspondence from the insurer denying benefits in letters dated February 16 and September 6. He did, however, find that a Dispute Resolution Form was attached to the January 7, 2011 letter, where payment of the IRRs was initially denied.

Yatar disputed whether the January 7 letter was indeed the one denying coverage.

“In making this argument, [Yatar] misinterprets the arbitrator’s decision,” the Court of Appeal concluded. “The arbitrator acknowledged that in his preliminary decision he erred in saying that the IRBs were denied in the February 16, 2011 letter. He corrected this finding in his reconsideration decision and said that it was the September 19, 2011 letter that ultimately refused the IRBs.

“The arbitrator then reiterated his central point that the January 7, 2011 letter had denied both IRBs and housekeeping and home maintenance benefits. He noted that a dispute resolution form had been attached to this letter.

“The arbitrator therefore concluded that, when the IRBs were finally denied by the letter of September 19, 2011, [Yatar] has been fully informed of the dispute resolution process. Therefore, he concluded that there was no deficiency that undermined the IRBs denial through the September 19, 2011 letter.”

In the end, Yatar went through mediation with the insurer, who extended the deadline for her to challenge the findings until April 2014. Yet she did not file a request to challenge the decision. of the court to deny benefits before March 16. , 2018 – well past the two-year deadline to launch a legal challenge.

Photo courtesy of iStock.com/MicroStockHub

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