Want an Order from LAT Compelling the payment of ongoing benefits after benefits reinstated by Insurer? Think again….

By Suzanne Clarke Jul 23, 2020

In M.S. and Unifund 18-000715/AABS, the Claimant sought entitlement to ongoing IRBs. Eight days before the Hearing, the Insurer reinstated the Claimant’s IRBs and issued payment for full arrears of these benefits. Even though the Insurer effectively resolved this dispute before the Hearing, the Claimant sought an Order from LAT that she was entitled to IRBs, so that she could take advantage of section 281(1) of the Insurance Act, which states, “after the Licence Appeal Tribunal issues a decision, the insurer shall not reduce benefits to the insured person on the basis of an alleged change of circumstances, alleged new evidence or an alleged error except as provided under this section”.

Adjudicator Paul Gosio held that since at the time the LAT Application was filed, the Claimant’s entitlement to IRBs was still in dispute, LAT  had jurisdiction over the matter, even though Unifund conceded the Claimant’s entitlement to IRBs and issued payments in arrears, after the Case Conference. Adjudicator Gosio decided that because there was no Tribunal decision on this dispute, as Unifund reinstated the Claimant’s IRBs before the Hearing, the dispute had ended.  As such, making a formal determination on the Claimant’s entitlement to IRBs would be a misapplication of the Tribunal’s resources. Therefore, Adjudicator Gosio dismissed the Claimant’s relief sought.

In M.I. and Coseco Insurance Company, 18-000742/AABS, the Insurer reinstated the Claimant’s IRBs with interest. The main issue before the Tribunal was whether it had jurisdiction to consider the Claimant’s application for ongoing IRBs even though these benefits were reinstated after the commencement of an Arbitration proceeding. The Claimant also requested the Tribunal issue an Order for ongoing payments of IRBs after reinstatement. In particular, the Claimant sought an Order from the Tribunal that the Insurer must continue to pay these benefits until the Tribunal issued an Order allowing the Insurer to terminate the benefits. Adjudicator Stephanie Kepman held that section 281(1) of the Insurance Act dealt with benefits after a decision from the Tribunal, which was not the case at hand, since no order was necessary from the Tribunal. It was therefore Adjudicator Kepman’s decision that the Tribunal did not have jurisdiction to consider the Claimant’s application for ongoing IRBs plus Interest.

Adjudicator Gosio and Adjudicator Kepman had different views as to whether the Tribunal has jurisdiction over matters that the parties resolve prior to a decision being rendered by the Tribunal. However, they agree that once a benefit is paid, there is no need for an Order or decision from the Tribunal on a particular benefit, and as such, the Claimant has no right to seek relief from the Tribunal for ongoing entitlement to the benefits that the parties have resolved.

Suzanne Clarke is the author of this blog and member of the Licence Appeal Tribunal practice group. If you have a question about these decisions or a similar file, please contact Suzanne at 416-777-5226.

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