Section 56, subsection 280(2) of the Statutory Accident Benefits Schedule (SABS) sets out limitations on how long an applicant has to appeal an insurer’s refusal to pay a claim. That limitation expires two years after the insurer refuses payment.
Of course, limitation periods aren’t as cut and dry as that. Two cases specifically showcase how limitations can – and are – interpreted differently by the Courts: Beric v. Guarantee Company of North America and Higashi v. Western Assurance.
These cases regard the provision of Insurers Examination (IE) reports under Section 37(5) of the SABS and its impact on limitation periods. Specifically, they considered the issue of whether the failure to meet the regulations for the provision of IE reports as outlined in Section 37(5) invalidates the limitation period. As we will see, both cases had very different outcomes.
Beric v. Guarantee Company of North America
Section 37(5) of the SABS states:
“Within 10 business days after receiving the report of an examination under section 44, the insurer shall give a copy of the report to the insured person and to the person who completed the disability certificate, if one was provided in accordance with subsection (1).”
In Beric v. Guarantee, the Respondent did not provide a copy of the IE to the doctor who completed the OCF, although they did provide one to the Applicant. The Respondent argued that the Applicant was aware of the denial and received a copy of the IE report, which should be enough to trigger the limitation period regardless of whether or not the person who completed the disability certificate was provided a copy of the IE report.
The License Appeal Tribunal (LAT) did not agree with those arguments. Instead, the adjudicator focused on Section 37(5), which they deemed “an important component of the termination process,” the fulfillment of which was a precondition to triggering the limitation period. The Tribunal therefore concluded that the Applicant was entitled to contest the Income Replacement Benefits (IRB) denial and proceed with her 2018 application.
Higashi v. Western Assurance
Similar to Beric, Higashi v. Western Assurance was an appeal involving the matter of the limitation periods laid out in Section 56 of the SABS. The appeal also involved an application for IRB’s and the issue of whether or not the provision of IE’s to all parties is necessary to triggering the limitation period.
In this case, the Appellant argued against their insurer’s refusal to continue to pay IRB’s. Her central argument was that the denial in July of 2015 was not valid because they failed to provide IE’s to the person who completed the disability certificate. Like in Beric, the Appellant had received a copy, but only one of the seven was provided to her practitioner.
The Appellant’s main argument was that her ability to make an informed decision regarding whether or not to challenge the termination of her benefits was compromised. She argued that her physician was not fully informed because he did not receive those critical reports.
In the original decision, the LAT had a very different conclusion than they did in Beric. The Tribunal concluded that the Applicant was clearly aware of the refusal of benefits and that the failure of the Respondent to provide IE reports to the practitioner who filled out the disability certificate did not invalidate that refusal.
What’s more, on this appeal, the Court agreed with that conclusion. The Applicant used the findings of Beric to justify her case, but the Court stood by the notion that she had been provided enough information to know that she was refused benefits and to decide whether to challenge that refusal since July of 2015. As such, the appeal was dismissed.
Takeaways
Higashi indicates that the Court may not hold insurers to the language of Section 37(5) like the LAT did in Beric. Indeed, they asserted that this subsection “is not linked to refusal of benefits in particular.” Meaning that, as long as the Applicant was provided the report, failing to provide a copy to practitioners or the person who completed the disability certificate does not invalidate a refusal due to the limitation period being up.
Central to this conclusion is that, as long as an Applicant is provided with the IE reports, they are free to share them with their doctor. But, considering the only reason a physician might need to have a copy of an IE report is to provide an opinion as to whether or not an Applicant should challenge a refusal of benefits, failure to provide them a copy does not invalidate a refusal.
Have You Been Denied Benefits?
The Beric and Higashi cases shared similar issues. That is, they considered the refusal of IRB’s citing the expiration of the two-year time limit and the failure of insurer’s to provide copies of IE’s to practitioners as well as Applicants. Yet both had very different outcomes; one in which the LAT upheld that Section 37(5) requires the provision of reports to Applicant’s and their practitioners and the other in which the failure to provide reports to practitioners was not enough to invalidate a refusal based on time periods.
When it comes to receiving the benefits you’re entitled to, the law isn’t always cut and dry, which is why you need the help of an experienced professional. Contact us today to find out what you’re entitled to.
