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September 15, 2010

Accident Benefits: Application Forms Not Needed

The following blog entry was contributed by Alexandra Lacko, articling student. She will be making regular contributions to our blog in the coming weeks.

In ING Insurance Co. of Canada v. TD Insurance Meloche Monnex, [2010] O.J. No. 3549 (C.A.), the Court of Appeal for Ontario recently answered a question on what triggers an insurance company’s obligation to pay accident benefits.

The question answered in this case was whether forms completed by a chiropractor who treated the claimants and sent the forms to ING, amount to “completed applications for benefits”, thereby triggering ING’s obligation to pay benefits.

J.A. Gillese held that “an application for accident benefits need not be on a certain form in order to be valid - it need only provide sufficient particulars to reasonably assist the insurer with processing the application, identifying the benefits to which the applicant may be entitled, and assessing the claim.” She further stated that the arbitrator was correct to find that ING had failed to take reasonable steps to obtain the necessary additional information from the claimants.

The four claimants were injured in a motor vehicle accident and were all treated by the same chiropractor for treatment of their injuries. The chiropractor forwarded the four forms to ING because she said she had seen ING’s contact information in her file and wanted to receive payment for the services she had provided to the claimants.

The forms indicated they were accident benefit claims and provided a claim number, policy number and the date of the accident. Each claimant’s full name, address, telephone number, gender and birth date was filled out.

ING tried to contact the claimants based on the information in the forms and found that the telephone number was out of service. ING received a cell phone number for one of the claimants from the doctor. The claimant was reached briefly but did not call ING back. As well, an ING adjuster sent letters to each of the claimants, but all of the letters were sent to one address which was no longer the address of any of the claimants. ING did not receive responses to any of its letters, and ING was not contacted by any of the claimants. The claimants did not send ING applications for accident benefits in OCF-1 Forms. ING closed the file for the four claimants on July 20, 2007.

On July 25, 2007, TD opened accident benefit claims files for the claimants and received four OCF-1 Forms from the claimants’ authorized representative. ING and TD disagreed about which had been the first insurer to receive a completed application for accident benefits within the meaning of s. 2 of O. Reg. 283/95 to the Insurance Act, R.S.O. 1990, c. I.8.

The matter went to arbitration to be determined, in which the arbitrator held that ING was responsible for the payment of benefits because the forms from the chiropractor constituted a “completed application for benefits”. ING’s application to the Superior Court was dismissed. The Court of Appeal also dismissed the appeal.

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