The Importance of Disability Certificates in a Claim for Accident Benefits

September 24th, 2013 by

This blog is written by our summer student, Ira Marcovitch.

In a recently released decision, the Financial Services Commission of Ontario (“FSCO”) has highlighted the importance of submitting a Disability Certificate in a timely fashion when making a claim for accident benefits under an automobile insurance policy.

In Anthonipillai v. Security National, Ms. Anthonipillai (the “insured”) was involved in a motor vehicle accident in April 2008. As a result of the accident, the insured applied for accident benefits from her insurer, Security National (“Security”), namely housekeeping and caregiver benefits. Security sent Ms. Antonipillai a package of forms to be submitted, including a Disability Certificate to be completed by her doctor and remitted to Security. However, the insured failed to complete or remit the Certificate. On numerous occasions, Security contacted her, informing her that until a completed Disability Certificate was provided, no benefits would be payable.

The Importance of Disability Certificates in a Claim for Accident BenefitsIt was only 3 ½ years later, after benefits had been denied, and the discovery and pre-hearing had taken place, that the insured finally submitted a completed Disability Certificate. However, this certificate only addressed the caregiver benefit, and not the housekeeping. Unsurprisingly, Security sought to deny both the caregiver and housekeeping benefits on the basis that the insured had not submitted the required documentation. For her part, the insured argued that, because Security had continued to adjust her claims and pay certain benefits, they had waived their right to demand a Disability Certificate.

In his ruling, the arbitrator sided with Security. He found that the insurer had an obligation to continue to adjust her claims, whether or not Ms. Anthonipillai was complying with her obligations to submit the proper forms. As such, the continuance of adjustment and payment could not constitute a waiver. He found that, because the insured had failed to provide a Disability Certificate certifying her entitlement to housekeeping benefits, such were not payable. The arbitrator then turned to the issue of caregiver benefits, for which the insured had eventually submitted a Disability Certificate.

On the issue of the caregiver benefits, the arbitrator held that if Security had promptly communicated that the insured would be permanently disentitled to benefits if no Disability Certificate was received, it could deny caregiver benefits to the insured under s.35(13) of the Statutory Accident Benefits Schedule. However, the arbitrator found that Security did not meet its obligation to fully explain the consequences of her failure to submit a completed Disability Certificate, and thus could not rely on s.35(13). However, in the end, the arbitrator found that Ms. Anthonipillai failed to establish a claim to caregiver benefits based on the merits, and was thus not entitled to any benefits.

This case highlights the importance of Disability Certificates in Accident Benefit Claims, where not only the need to ensure that all documentation needs to be submitted promptly in a claim against an insurer, but the potential complications and their potentially ruinous consequences for an accident benefit claim. If you have been denied benefits by your insurer, contact one of our lawyers to discuss a potential resolution to your claim.

For more information on our personal injury practice and Lawyers, please visit our Personal Injury Law page.


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