Late But Legit: Insured Wins Benefits Battle

The Ontario Superior Court of Justice overturned a decision of the License Appeal Tribunal (LAT) which had upheld the insurer’s decision to deny the insured’s claim for accident benefits on the basis that the insured had failed to provide timely notice of the claim for benefits. 

Insurance law – Accident and sickness insurance – Benefits – Notice

Hussein v. Intact Insurance Co., [2025] O.J. No. 519, Ontario Superior Court of Justice, February 7, 2025, H.E. Sachs, N.L. Backhouse and S.T. Bale JJ.

The insured was involved in a motor vehicle accident in February 2019 and notified his insurer, Intact Insurance, of the accident the next day. However, the insured did not apply for accident benefits until 17 months later, claiming he was unaware of his entitlement to accident benefits until advised by a paralegal. The insurer denied the claim for failing to meet the seven-day notice requirement under the Statutory Accident Benefits Schedule (SABS), O. Reg. 34/10 (SABS). The insured applied to the License Appeal Tribunal (LAT) to resolve the dispute with the Insurer. The LAT ruled against the insured, taking the position that merely reporting the accident was insufficient to satisfy the SABS notice requirement; he needed to notify the insurer of his intent to claim benefits. The LAT also found the insured’s delay explanation of being ignorant to his entitlement of benefits was not credible. The insured applied to the LAT for reconsideration and the LAT upheld its decision, confirming that insurers have no obligation to inform claimants of accident benefits unless explicitly notified of injuries.

The insured appealed the LAT decision to the Ontario Superior Court of Justice. The Court allowed the appeal and set aside the LAT decision, finding that the insured’s notification to the insurer that he had been in an accident with heavy damage was sufficient notice to satisfy the seven-day deadline for notice under the legislation. Fundamental to the Court’s decision was the fact that the SABS is consumer protection legislation, which must be interpreted in a manner consistent with its objective which is to reduce economic dislocation and hardship for victims of motor vehicle accidents. The Court noted that the LAT’s narrow interpretation of the notice requirement undermined the SABS purpose. The Court suggested a reasonable insurer would assume that an insured who has been in an accident intends to access all the benefits available to them under the policy. The Court highlighted that the insurer had an obligation under s. 32(2) of the SABS to send out the necessary application forms and an explanation of the available benefits; this is an interpretation that fosters the consumer protection purpose of the SABS. The matter was referred back to the LAT and the insured was awarded $6000 in costs.

This case was digested by Aman Taggar and edited by Steven W. Abramson of Harper Grey LLP.  If you would like to discuss this case further, please feel free to contact them directly at [email protected] or [email protected].