Our injured client from a May 2017 motor vehicle accident sought medical and rehabilitation benefits from her insurer, Intact Insurance Company. Intact denied her request.
Subsequently, our client brought an application to the Licence Appeal Tribunal (“LAT”) to determine whether she was entitled to medical and rehabilitation benefits, an award, and interest. In response, Intact brought a motion arguing that our client was barred from proceeding with her application because she failed to attend section 44 insurer examination (“IE”) requests.
At the motion hearing, adjudicator Jarda denied Intact’s motion to bar our client from proceeding with her application because Intact’s notices of examination did not comply with the content requirements noted within sections 38(8) and 44(5) of the Statutory Accident Benefits Schedule (“Schedule”).
The adjudicator cited 16-003316/AABS v Peel Mutual Insurance Company, a 2018 LAT decision where the Tribunal found that an insurer’s medical reasons for denying a plan should include specific details about the insured’s condition forming the basis of the insurer’s decision. Further, an unsophisticated person should easily understand the required information and reasons to make an informed decision in response.
In the case at bar, our client submitted a treatment plan for a hearing assessment and neuro-optometric evaluation in January 2020. On January 22, 2020, Intact did not agree to pay for the hearing assessment and evaluation, arguing that the goods and services recommended may be covered through OHIP and that it lacked medical documentation finding that our client’s impairments were a direct result of the accident. On February 4, 2020, and February 10, 2020, our client’s case manager provided additional medical information concerning the above treatment plan. On March 23, 2020, Intact reaffirmed its denial of the hearing assessment for the following reason: “to determine if the issues the insured is having with her hearing aids is a direct result of the accident. Causation.” In addition, Intact advised that arrangements had been made for our client to participate in an independent medical assessment to determine whether the treatment was reasonable and necessary and resulted from the accident. No notice of examination was provided. On March 31, 2022, and April 6, 2020, Intact provided notices of examination for the same exact reason as on March 23, 2020. On April 11, 2020, our client objected to the proposed IE’s because the notices did not comply with the Schedule. On June 4, 2020, and June 22, 2020, Intact issued two more notices of examination that were virtually identical to the previous notices.
The adjudicator agreed with our client that Intact’s notices of examination did not comply with section 44 of the Schedule because they failed to offer any rationale as to why Intact was arranging the IE’s and did not provide any medical reasons for arranging the assessments.