Decision clarifies extent of obligation to give notice of right to dispute refusal of benefits
In proceedings arising from a motor vehicle accident, the Ontario Divisional Court upheld a decision finding that an insurance company had fulfilled its obligation to notify a claimant of her right to dispute the partial denial of accident benefits.
In Sparks v. Primmum Insurance Company, 2026 ONSC 3803, the appellant was involved in an accident on Feb. 6, 2020.
On Feb. 6, 2022, the appellant submitted a treatment and assessment plan (OCF-18) for $17,967 to prepare a catastrophic impairment assessment (OCF-19) and to obtain various assessments supporting her claim.
Through a letter dated Feb. 15, 2022, the respondent insurer informed the appellant of its partial approval of the OCF-18 for $14,577 and its refusal to pay the balance of her claim.
The letter attached a form titled “Your Right to Dispute the Insurance Company’s Determination of Your Claim for Statutory Benefits.”
On Apr. 13, 2023, the appellant brought an application assailing the insurer’s partial denial of benefits. On May 1, 2024, she unilaterally withdrew her application without preconditions or an agreement to toll the limitation period.
In an application submitted to the Licence Appeal Tribunal on July 30, 2024, over two years after receiving notice of the partial denial, the appellant disputed the insurer’s refusal to pay $3,390 in benefits.
A hearing addressed the preliminary issue of whether the appellant had filed her application more than two years after the insurer’s partial denial, thus exceeding the relevant limitation period in s. 56 of the Statutory Accident Benefits Schedule (SABS).
On Apr. 28, 2025, the tribunal’s adjudicator determined that the insurer’s notice informing the appellant of her right to dispute met the requirements of s. 54 of the SABS, thus triggering the commencement of the two-year limitation period under s. 56.
The appellant appealed and applied for judicial review of the adjudicator’s decision.
The Divisional Court of the Ontario Superior Court of Justice dismissed the appeal and the judicial review application, without costs, as the parties had sought none.
First, the court rejected the appellant’s argument that the adjudicator had wrongly found that a s. 54 notice did not require an insurer to notify a claimant of every step of the reconsideration and appeal process or to provide timelines and contact information for various courts.
Given s. 54’s clear language, the court ruled that the appellant overstated the impact of the SABS’s consumer protection purpose.
Under s. 54, the court held that the insurer should notify the claimant only about their right to dispute, specifically the right to apply to the tribunal to resolve a dispute involving the insurer’s refusal to pay accident benefits under s. 280(2) of Ontario’s Insurance Act, 1990.
The court explained that this right to dispute did not cover avenues such as reconsideration under Ontario’s Licence Appeal Tribunal Act, 1999, as well as appeal and judicial review.
Next, the Divisional Court rejected the applicant’s argument that the adjudicator should have found the insurer’s s. 54 notice misleading.
The court acknowledged that the adjudicator erred in their description of s.54’s purpose by relying on Turner v. State Farm Mutual Automobile Insurance Co., 2005 CanLII 2551 (ON CA).
The court considered Turner distinguishable because that case addressed the question of whether the insurer had sufficiently explained the cancellation of accident benefits under s. 24(8) of the SABS, not the current issue of an insurer’s obligation to notify a claimant of the right to dispute a denial of benefits under s. 54.
Despite this error, the court ultimately decided that the adjudicator reasonably determined that the insurer’s notice complied with s. 54’s requirements.
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