Canada: Is A Medical Reason Required To Deny Benefits And When Does The Limitation Expire To Appeal The Denial?

Republished with permission from the Insurance Brokers Association of Alberta's magazine The Alberta Broker (June/July 2023).

When an insured is involved in an accident, their insurer pays for various medical and economic benefits. What happens when an insured returns to work full-time and his income loss benefits are terminated by the insurer? Does an insurer have to give a medical reason for termination as part of the denial? At what point does the limitation to appeal the denial by the insurer expire?

The Ontario Court of Appeal recently addressed these issues in Varriano v Allstate Insurance Company of Canada ("Varriano").¹

Nunzio Varriano ("Mr. Varriano") was injured in a motor vehicle accident on September 30, 2015. He applied to his own insurer, Allstate Insurance Company of Canada ("Allstate"), for income replacement benefits ("IRBs") pursuant to the Ontario Statutory Accident Benefits Schedule ("SABS").²

Allstate paid income replacement benefits to Mr. Variano up until December 2, 2015. On December 30, 2015, Allstate notified Mr. Varriano that his income replacement benefits would cease effective December 2, 2015 as he had returned to full-time work. On July 1, 2018, Mr. Varriano again ceased working and applied to resume his income replacement benefits. These benefits were denied by Allstate based on their correspondence dated December 30, 2015.³

On September 28, 2018, Mr. Varriano filed an application before the License Appeal Tribunal ("LAT") disputing the decision to deny his income replacement benefits. Allstate took the position that the application was time barred as it was made more than two years after the initial benefits letter sent on December 30, 2015. The adjudicator agreed that Allstate's termination letter met the legislative requirements of s. 37(4) of the SABS and that the limitation period commenced on December 30, 2015. Mr. Varriano sought a reconsideration of the adjudicator's decision which was dismissed.⁴

Mr. Varriano appealed to the Division Court which overturned the decision of the LAT adjudicator. The Divisional Court held that Allstate's Benefits Letter did not meet the requirements of s. 37(4) of the SABS as it failed to provide a medical reason for the termination of the income replacement benefits.⁵

Allstate appealed to the Ontario Court of Appeal. The Ontario Court of Appeal had to decide if Allstate's Benefits Letter met the statutory requirements and whether a medical reason had to be given to terminate benefits under the SABS.⁶

The Ontario Court of Appeal noted the following when making their decision:

1. Allstate's Benefits Letter dated December 30, 2015 advised that Mr. Varriano's income replacement benefits would be terminated because he had returned to full-time work. The letter also outlined his right to dispute the insurer's determination. On July 1, 2018, Mr. Varriano stopped working again. He sought to resume his income replacement benefits and Allstate denied the resumption of benefits based on their December 30, 2015 letter.

2. Section 37(2) of the SABS allows an insurer to discontinue an insured's benefits for one of the following reasons:

37(2) An insurer shall not discontinue paying a specified benefit to an insured person unless,

(a) the insured person fails or refuses to submit a completed disability certificate if requested to do so under subsection (1);

(b) the disability certificate submitted on behalf of the insured person does not support the insured person's continuing entitlement to the benefit;

(c) the insurer has received the report of the examination under section 44, if the insurer required an examination under that section, and has determined that the insured person is not entitled to the benefit;

(d) the insurer is entitled under subsection (7) to refuse to pay the specified benefit;

(e) the insured person has resumed his or her pre-accident employment duties;

(f) the insurer is no longer required to pay the specified benefit by reason of subsection (7), paragraph 2 of subsection 28 (1), subsection 33 (6) or section 57 or 58; or

(g) the insured person is not entitled to the specified benefit for a reason unrelated to whether he or she has an impairment that entitles the insured person to receive the specified benefit. [Emphasis added.]⁷

Pursuant to s. 37(4), an insurer has to provide notice to the insured of the reasons for the denial of benefits as follows:

37(4) If the insurer determines that an insured person is not entitled or is no longer entitled to receive a specified benefit on any one or more grounds set out in subsection (2), the insurer shall advise the insured person of its determination and the medical and any other reasons for its determination. [Emphasis added.]⁸

A valid notice under s. 37(4) starts the two year limitation running to bring an application before the LAT disputing the decision to terminate.⁹

The Court held that the modern approach to statutory interpretation required that the statute was to be read in its entire context and in its grammatical and ordinary sense harmoniously with the scheme and object of the Act and intention of Parliament (citing Rizzo & Rizzo Shoes Ltd. (Re), [1998] 1 S.C.R. 27 at para 26. The Court determined that the Divisional Court's interpretation of the word "and" in s. 37(4) failed to take into account that it could be used in the several rather than joint sense. The Court held that the insurer just had to provide a reason or reasons for their termination. An insurer only has to provide a medical basis for the termination if that forms part of the reason for the denial.¹⁰

The Court also held that the interpretation noted above met the purpose of the notice provision in the SABS. The Court of Appeal also held that s. 37(4) is not a coverage provision.¹¹

As the notice was not deficient, Allstate had triggered the limitation period by terminating Mr. Varriano's benefits. The appeal was allowed and the decision of the Divisional Court set aside and the decision of the LAT affirmed.¹²

This decision is a helpful reminder of the importance of an insurer being clear when providing the reasons of termination in notice letters and provides clarity on the application of s. 37(2) and (4) of the SABS. A medical reason is not required to terminate benefits when other non-medical reasons have been provided.

Footnotes

1. Varriano v Allstate Insurance Company of Canada, 2023 ONCA 78 ("Varriano")

2. Ibid at para 1.

3. Ibid at paras 1 and 8.

4. Ibid at paras 9 and 14-15.

5. Ibid at paras 16-18.

6. Ibid at para 19.

7. Ibid at para 10.

8. Ibid at para 11.

9. Ibid at para 13.

10. Ibid at paras 23-24.

11. Ibid at paras 32-34.

12. Ibid at para 38.

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