Anyone injured in a collision in Ontario is eligible for accident benefits under the Statutory Accident Benefits Schedule (SABS). As a result, if you have been injured in a motor vehicle accident, it is important to make a claim with your insurance company in a timely manner and understand your options in the event it is denied. 

We recently reported on the different types of accident benefits available under the SABS and how to make a claim to your insurance company. This article follows by looking at appealing an insurance company’s refusal to pay benefits to the Automobile Accident Benefits Service through the court system.

What is the Statutory Accident Benefits Schedule?

The SABS is a regulation made under the Insurance Act. The coverage set out in the regulation is provided by law under every auto insurance policy. These benefits provide compensation, regardless of fault, if you, your passengers, or pedestrians are injured or die as a result of your accident.

The benefits provide coverage beyond OHIP and are paid by the insurance company. They can help you deal with an accident’s physical and financial fallout. 

Applying to the Automobile Accident Benefits Service

As we wrote about previously, it is possible to apply to the Automobile Accident Benefits Service (AABS), a division of the Licence Appeal Tribunal, to resolve a dispute. Under the Insurance Act, all disputes in respect of an insured person’s entitlement to statutory accident benefits or in respect of the number of statutory accident benefits to which an insured person is entitled need to be brought to the AABS.

Importantly, you need to file an application with the AABS within two years after the insurer refuses to pay the amount claimed. 

Can you appeal a decision of the AABS?

If you are not satisfied with the AABS adjudicator’s decision, you may have a number of options.

Asking the AABS to reconsider its decision

A party can ask the AABS to reconsider its decision by lodging a request within 21 days of the date of the decision. A request for reconsideration will only be granted in certain limited circumstances, such as where the AABS did not act with procedural fairness, made a significant error that would likely have affected the outcome, heard false or misleading evidence that would have affected the result, or there is new evidence that could not have reasonably been obtained earlier and would have affected the result. 

Appealing the decision to the Divisional Court

A party has a statutory right to appeal a decision of the AABS to the court, but only on a question of law. In other words, the decision can only be appealed if it contains a legal mistake. Appeals must be filed with the Divisional Court within 30 days of the date the AABS releases its decision.

Requesting a judicial review by the Divisional Court

A party is also entitled to request a judicial review of the AABS decision. The party needs to show that the AABS adjudicator failed to properly exercise its decision-making powers and committed an error that warrants action by the court. 

Injured person applied to the Tribunal many years after being denied accident benefits

The recent decision of the Court of Appeal for Ontario in Yatar v TD Insurance Meloche Monnex highlights the importance of challenging a denial of SABS benefits in a timely manner. 

The applicant was injured in a motor vehicle accident and submitted an application for accident benefits. Her insurer initially paid benefits but later stopped paying income replacement, housekeeping, and home maintenance benefits because she had not received a completed disability certificate within the requested timeframe. After attending the insurer’s medical examinations, the insurer confirmed the decision to deny benefits.

More than six years after this, and four years after mediation with the insurance company, the applicant applied to the Tribunal. The adjudicator found that the applicant’s claim was statute-barred because it had commenced more than two years after the denial of benefits by the insurance company. After a request for reconsideration, the adjudicator confirmed the decision. 

Court dismisses the applicant’s claim for statutory accident benefits 

The applicant appealed the Tribunal decision and also commenced an application for judicial review to the Divisional Court. The court dismissed the applicant’s claim, so the applicant appealed again to the Court of Appeal.

The Court of Appeal upheld the decision to dismiss the applicant’s claim for benefits. It said:

“it is evident from the amendments that the legislature made to the resolution of disputes over SABS that it intended to greatly restrict resort to the courts for the determination of those disputes. One can draw that conclusion from the fact that the legislature limited the statutory right of appeal to questions of law only. The result is that issues of fact or mixed fact and law are presumptively left to the Tribunal to determine, subject to the right to request a reconsideration.”

In relation to the appeal, the Court found that no questions of law were raised. In relation to the application for judicial review, it explained that it would only be in rare cases that the remedy of judicial review would be exercised, given the legislated scheme for the resolution of SABS disputes.

Finally, the Court explained that if a party intends to utilize both their right of appeal and their right to seek judicial review, the proceedings must be brought and heard together. 

Contact the Personal Injury Lawyers at Tierney Stauffer LLP About Your Accident Benefits Insurance Claim

Don’t lose the opportunity to bring a claim for statutory accident benefits by missing an important deadline. The personal injury lawyers at Tierney Stauffer LLP can help you appeal a denial of benefits by your insurance company so that you can recover financially and move on with your life. Please reach out to us by telephone at 1-888-799-8057 or contact us online to set up a free consultation with a member of our team.

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