Ontario Civil


Monthly care benefit not calculated based on number of hours caregiver unable to work

Applicant rendered paraplegic in motor vehicle accident. Applicant’s mother took unpaid leave of absence from job in order to care for applicant full-time. Pursuant to Statutory Accident Benefits Schedule (“SABS”), insurers required to provide certain no-fault benefits, including reasonable and necessary expenses incurred by or on behalf of insured for attendant care. Insurer took position that amount payable for attendant care benefits would be pro-rated based on 8 hours per day since mother had foregone only 40 hours per week paid work to care for applicant. Application judge held that insurer’s obligation not limited to care provided during 40 hours per week of paid work foregone by mother, concluding that insurer must pay attendant care benefits for entire 24 hours per day applicant required. Insurer’s appeal dismissed. Section 3 of SABS provides that expense in respect of attendant care costs not “incurred” unless insured received such care and person who provided care sustained economic loss as result of providing care. Issue was whether expense was incurred by insured with respect to attendant care services provided by mother outside of normal work hours. SABS incorporated in every standard insurance policy so principles applicable to construction of insurance coverage provisions applicable. Insurance coverage provisions to be interpreted broadly whereas coverage exclusions or restrictions to be construed narrowly. To extent “incurred” restricts coverage, it must be interpreted narrowly. Economic loss serves as threshold for entitlement to attendant care benefits. Amount of monthly care benefit to be calculated based on number of hours of each type of attendant care insured requires, subject to maximums. Monthly care benefit not calculated based upon number of hours family caregiver unable to work or quantum of economic loss sustained by caregiver.

Henry v. Gore Mutual Insurance Co. (Jul. 16, 2013, Ont. C.A., Janet Simmons J.A., Alexandra Hoy J.A., and G.R. Strathy J.A., File No. CA C55845) Decision at 216 A.C.W.S. (3d) 224 was affirmed.  229 A.C.W.S. (3d) 545.

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