In S.S. v. Economical, the Licence Appeal Tribunal found the claimant missed the limitation period to dispute the denial of attendant care and housekeeping benefits, which had been denied at 104 weeks, despite the claimant later being deemed catastrophically impaired. The Tribunal also found that subsequent payments of attendant care and housekeeping benefits, made in error by the insurer after the claimant was deemed catastrophically impaired, were irrelevant because the limitation period had expired well before the subsequent payments were made.
The claimant, S.S., was involved in a motor vehicle accident on July 29, 2009. The insurer paid the claimant attendant care and housekeeping benefits until the benefits were terminated pursuant to s. 18(2) and s. 22(2) of the SABS. This refusal to pay further attendant care and housekeeping benefits was communicated via a letter, dated October 4, 2011.
The claimant submitted an initial Application for Determination of Catastrophic Impairment (OCF-19), dated March 23, 2010, claiming impairment under criterion 1(e). The insurer assessed the claimant and found he was not catastrophically impaired under this criterion.
The claimant submitted two further OCF-19s, dated June 17, 2013 and January 8, 2014, under Criterion 8 and Criterion 7, respectively. On September 3, 2014, following the completion of s. 44 examinations, the insurer advised the claimant of their determination that he was catastrophically impaired. The insurer also mistakenly advised the claimant that he was entitled to attendant care and housekeeping benefits and paid him these benefits for approximately six months. Upon identifying the mistake, the insurer advised the claimant that benefits were paid in error and requested a repayment.
The claimant did not dispute the insurer’s denial of attendant care and housekeeping benefits until May 5, 2017.
Adjudicator Johal determined that the denial of October 4, 2011 was clear and unequivocal and complied with the principals set out in Smith v. Cooperators and the SABS. While the Adjudicator agreed that subsequent payments can negate a denial in certain cases, she agreed with the insurer’s position that, in this case, the claimant’s claim for ongoing attendant care and housekeeping benefits was already statue barred at the time of the subsequent payment. In other words, subsequent payments cannot revive a right that has been extinguished.
See S.S. v. Economical, 17-002867 (LAT)
Lisa has an insurance law practice that has focused exclusively on insurance defence for 15 years. Her practice focuses on complex insurance-related litigation, including accident benefits and bodily injury. Read more ...