Martin v. Fleming - Deductibles

The Court of Appeal has now released its decision in Martin v. Fleming, which can be found at the following link: Martin v. Fleming, 2012 ONCA 750 (C.A.)

At issue was the operation of the deductible where a plaintiff has been in multiple accidents.  The motions judge ruled that where the plaintiff has been involved in two accidents and the actions are tried together, there is a deductible for each action.

In a brief endorsement, the Court of Appeal dismissed the appeal. They followed the motion judge's reasoning that s. 267.5(7) is unambiguous and the plaintiff is subject to two deductibles.

Although this is a brief endorsement, it is important to those defending claims where the plaintiff has been in multiple accidents.  Insurers for each defendant retain the benefit of the deductible.

New Minor Injury Guideline

The new Statutory Accident Benefits Schedule (SABS) came into effect September 1, 2010. Among the key amendments, there has been a reduction of medical and rehabilitation benefits from $100,000.00 to $50,000.00. In some cases, this will be further reduced to $3,500.00 under the new Minor Injury Guideline (MIG).

The MIG applies to accidents that occurred on or after September 1, 2010, and replaces the Pre Authorized Framework for Grade I and II whiplash associated disorders. Section 268.3 of the Insurance Act requires that the MIG be considered in any determination involving the interpretation of the SABS.

An insured person’s impairment comes within this Guideline if the impairment is predominantly a minor injury. “Minor injury” is defined in the new SABS as a “sprain, strain, whiplash associated disorder, contusion, abrasion, laceration or subluxation and any clinically associate sequelae”. Each of these conditions are further defined to specify the severity of each to move it out of the “minor injury” category. For example, “whiplash associated disorder” is defined as “a whiplash injury that does not exhibit objective, demonstrative, definable and clinically relevant neurological signs, and does not exhibit a fracture in or dislocation of the spine”.

The objectives of the MIG are to speed access to rehabilitation for persons who sustain minor injuries in auto accidents, improve utilization of health care resources, provide certainty around cost and payment for insurers and regulated health professionals, and be more inclusive in providing immediate access to treatment without insurer approval for those persons with minor injuries.

Many accident victims may now find their benefits reduced to $3,500.00 and if they do not have a tort claim, they may have little alternative for additional medical coverage. The Financial Services Commission of Ontario expects the MIG to capture 30%-40% of accident claims.

Section 18(2) provides for an exclusion from MIG if the insured person’s health practitioner determines and provides compelling evidence that the insured person has a pre-existing medical condition that will prevent the insured person from achieving maximal recovery from the minor injury if subject to the $3,500.00 limit. This exception raises the question of what the courts will consider to be “compelling evidence”.

- Kristen Dearlove, Student-at-Law

Court of Appeal Comments on s. 132 of the Insurance Act

The Court of Appeal recently commented on s. 132 of the Insurance Act. Section 132 provides that a person who obtains a judgment against an insured person which has not been satisfied may recover that amount from the insured’s insurer.

In Walker v. Sovereign General Insurance Co., [2011] O.J. No. 4106 (C.A.), the Walkers obtained a judgment against Sun Shelters Industries Inc. for damages sustained in a parking lot slip and fall. Sun Shelters went bankrupt and could not pay the judgment, so the Walkers brought an action under s. 132 against Sun Shelters’ insurance company, Sovereign. Sovereign’s position was that it did not receive proper notice as required under the CGL policy and as a result was not required to defend the action or indemnify Sun Shelters or the Walkers.

The Court of Appeal held that notice of a claim can be given either by the insured or by a person on behalf of the insured. In this case, notice was given to Sovereign by a co-defendant. The Court noted that if notice is given by someone other than the insured, the person should have sufficient proximity to give adequate details of the claim:

36 Given its purpose and importance, if the notice is to be given for an insured instead of by the insured itself, the person giving it should have sufficient proximity to the claim to have knowledge of the information required by s. 3(a). Emshih was just such a person. It owned the property where the accident occurred; it was a defendant in the original action; and it cross-claimed against Sovereign's insured. In giving notice to Sovereign, Emshih was giving notice for Sun Shelters as contemplated by s. 3(a) of the policy.

Sovereign had actual notice of the claim and made a conscious decision not to defend. If the insurer had no knowledge of the claim, no opportunity to investigate or negotiate a settlement, it may be that the decision would be different.

- Tara

Deductibility of Statutory Accident Benefits

Sutherland v. Singh, [2011] O.J. No. 2901 (C.A.)

The plaintiff was eligible for income replacement benefits (IRBs) and caregiver benefits (CGBs). He elected to receive CGBs. Under s. 267.8(1) of the Insurance Act, damages are reduced by payments for statutory accident benefits that the plaintiff received or that were “available”. The issue on appeal was whether IRBs were “available” to the plaintiff (thus allowing the tort defendant to deduct them) even though he elected to receive CGBs. The Court of Appeal held that the answer is “no”.

Justice Gillese held that once the plaintiff elected to receive CGBs, IRBs were no longer available to him. The purpose of s. 267.8 is to prevent double recovery. The effect of allowing the defendants to deduct CGBs that the plaintiff received as well as IRBs that he never received would be to create a windfall for the defendant.

Public Transit

This blog was prepared by Jennifer Stirton.

The Insurance Act has been amended by Bill 173, the Better Tomorrow for Ontario Act (Budget Measures), 2011, which received Royal Assent on May 12, 2011.

The amendments relate to incidents involving public transit and make two major changes. First, owners and drivers of public transit vehicles are not protected by subsections 267.5(1), (3) and (5) of the Insurance Act, which provide threshold protections and limit income loss claims, if the public transit vehicle does not collide with another automobile or any other object in the incident. In other words, public transit drivers and owners are not protected defendants unless there is a collision. The second major change is the addition of subsection 268(1.1), which provides that occupants of public transit vehicles who are injured are not entitled to statutory accident benefits if the public transit vehicle does not collide with another automobile or any other object.

These changes are clearly aimed at passengers who allege injury arising from incidents that do not involve collisions, such as sudden start/sudden stop claims. While it will reduce the cost of accident benefits being paid, it may result in an increase in tort actions against defendants who are no longer entitled to statutory protections.

The Appraisal Process in s. 128 of the Insurance Act

Letts v. Aviva Canada Inc., [2010] O.J. No. 5801 (S.C.J.)

This case deals with the appraisal process in s. 128 of the Insurance Act.

The plaintiffs made a fire loss claim and prepared a 56 page Request to Admit which contained an inventory of items they allege were destroyed or damage by the fire. They argued the insurer was required to specify the items took issue with as a condition precedent to the appraisal process.

Justice James disagreed:

While this may make sense in an appropriate case, I do not agree with the insureds that the insurer must provide a detailed response to the claim of the insureds before being able to invoke the appraisal mechanism contemplated by Section 128 of the Insurance Act.

Section 148 of the Act sets out what needs to be done prior to the appraisal process: a specific demand must be made and proof of loss delivered. Nothing else is required.

Defence "Life Care" Assessment

This entry was prepared by Alexandra Lacko, articling student.




In the case of Vanderidder v. Aviva Canada Inc., 2010 ONSC 6222, the moving party sought an order compelling the plaintiff, Vanessa Vanderidder to participate in a life care plan assessment by a certified life care planner.

The action arose out of an accident in which the plaintiff sustained an injury when a rock fragment fell from a truck, deflected from the road surface, went through her open car window and struck her in the head. The plaintiff alleged that she sustained serious injuries which caused permanent and serious disfigurement and serious impairments of important physical, mental and psychological functions. She also alleged that she continued to suffer and required treatment, and would continue to suffer from the effects of her injuries for an indefinite period of time. The plaintiff claimed damages for future health care costs as a result of the effects of the injuries on the activity of the plaintiff.

In support of Vanessa Vanderidder’s claim for future health care costs, counsel for the plaintiff served a future care cost report authored by Keith C. Hayes, Ph.D. The report was analysed by an actuary and placed a present value on the plaintiff’s future health care needs at $719,901.00.

As a result of the substantial monetary claim of the plaintiff, the moving party wished to have Vanessa participate in a life care assessment/future care cost assessment by an individual who had a Bachelor of Science in Occupational Therapy and was defined as a “practitioner” pursuant to s. 52 of the Evidence Act, R.S.O. 1990, c. E.23. The basis for the moving party’s motion for the life care assessment/future care cost assessment was prejudice.

The position of the responding party, Vanessa Vanderidder, was that the moving party had not deduced any evidence that the requested assessment was necessary to aid a health practitioner as a diagnostic tool.

Plaintiff’s counsel asked Justice Granger to recuse himself from hearing the motion on the grounds that in Kozhani v. Gelbart, [2010] O.J. No. 1348, Justice Granger ordered the plaintiff to submit to a life care assessment/future care cost assessment by an occupational therapist without a health practitioner requiring the assessment as a diagnostic tool. Plaintiff’s counsel suggested that based on Justice Granger’s earlier decision, there was a reasonable apprehension of bias and that Granger J. should recuse himself from hearing the motion. Justice Granger went through the test for bias and found that plaintiff counsel’s apprehension was an apprehension of lack of success rather than an apprehension of bias and Justice Granger did not recuse himself.

In coming to his decision on the assessment, Justice Granger underwent an analysis of the case law in the area of non-medical expert assessment. Justice Granger stated that:

It would seem to me that if Vanessa Vanderidder elects to place before the court evidence concerning her future care needs as determined by a non-health practitioner, she can hardly be heard to claim that it would be unfair to order her to submit to such an assessment by a person of the choosing of the defence.

The Court concluded that “fairness can only be achieved by ordering Vanessa Vanderidder to participate in a life care assessment by a person other than a “health practitioner” notwithstanding that there is a lack of evidence before me from a health practitioner that such an assessment is needed by a health practitioner as a “diagnostic aid.”

The plaintiff was therefore ordered to participate in a life care plan assessment by the certified life care planner and occupational therapist. The Court’s goal was to achieve fairness in the trial process in order to create a “level playing field” for trial.

Mandatory Mediation in Motor Vehicle Tort Claims

The Court of Appeal for Ontario has recently held that the refusal of an insurer to mediate a motor vehicle tort claim should attract cost consequences, per subsections 258.6(1) and (2) of the Insurance Act. See Keam v. Caddey, 2010 ONCA 565.

Significantly, the insurer had refused to mediate on the basis that it was of the opinion that the plaintiff's injuries did not meet the threshold test under the Insurance Act. Also significant was the fact that the Court of Appeal said that the offer to settle made by the insurer prior to trial, although a low offer of just $17,500, was an acceptance by the insurer that there was a potential claim to litigate - and therefore mediate.

The consequence of this decision might be to limit offers to settle in cases where insurers would otherwise make a low offer to settle in order to avoid the costs of a trial, especially where threshold is an issue. The other consequence, of course, is that insurers now will have to undertake the expense of mediation even where there is little or no chance of reaching a settlement.

The facts of the case are: After examinations for discovery, plaintiff's counsel wrote counsel for the insurer asking if they could mediate the claim pursuant to s. 258.6 of the Insurance Act. The insurer ignored the first letter. Plaintiff's counsel wrote again. In both letters plaintiff's counsel referred to costs consequences following trial if the insurer failed to participate. The insurer then responded that it would not mediate because it did not think the plaintiff's injuries met threshold. A year later, the insurer made an offer to settle for $17,500 plus interest and costs. The plaintiff won the trial and plaintiff's counsel sought substantial indemnity costs against the insurer for the failure to mediate, which the trial judge refused.

The Court of Appeal, however, found that the insurer had failed to comply with its statutory obligation to mediate per s. 258.6. The appropriate costs consequences were a "significant remedial penalty" in the amount of $40,000 in addition to the costs already awarded by the trial judge for the usual partial indemnity costs award.

Ontario Government Proposes New Auto Insurance Options

According to The Globe and Mail, the Ontario government is proposing to allow consumers to purchase less auto insurance coverage in order to keep down their auto insurance premiums.

Proposed changes include:

- lower the minimum medical and rehabilitation coverage for auto insurance to $50,000 from the current $100,000;
- adding a new deductible for property damage; and
- removing an insurer's right to an assessment from their own doctor if they disagree with the findings of the insurance company's health provider.

Proof of Loss

Section 136 - "No action shall be brought for the recovery of money payable under a contract of insurance until the expiration of sixty days after proof, in accordance with the provisions of the contract,

(a) of the loss; or

(b) of the happening of the event upon which the insurance money is to become payable,
or of such shorter period as is fixed by the contract of insurance."

I would take this to mean that if a court action is started before sixty days have elapsed that the insurer may bring a motion to dismiss the action.

Is this a complete bar to a court action?

The preceding section, s. 135 of the Insurance Act, requires insurers to "furnish forms" for proof of loss to the insured. Insurers are required to send these "Proof of Loss" forms to insured claimants.

My question is this, if the insured fails to complete and return these "Proof of Loss" forms but in all other respects cooperates with the insurer and the insurer conducts a thorough investigation of the loss, can the insurer rely on the failure to complete and return the "Proof of Loss" forms as a bar to the insured's action? Or can there be "deemed" notice of proof of loss in certain circumstances? Finally, what if the "Proof of Loss" forms are completed and returned to the insurer but the insured commences her/his court action prior to waiting sixty days?