Accident Benefits: Lessons from the Past with the Hope for a Better Insurance Product in the Future

• Author: Jennifer Griffiths, Eric K. Grossman, and Christine McKenna
• Pages: 263-331



AccidentBenets

LessonsfromthePastwiththeHopefora

BeerInsuranceProductintheFuture

JenniferGrithsEricKGrossmanand

Christine McKenna*

A. INTRODUCTION

TenyearsagoourrmparticipatedintheLawSocietySpecialLectures

onPersonalInjuryLawandprovidedanoverviewofthestatutoryac-

cidentbenetsregimeinOntarioasitexistedatthattimeInthecon-

clusionofthatpaperwecommentedthattherewereanumberoflive

issuesintherealmofaccidentbenetsthathadyettoreceiveadjudica-

tiveinterpretation

Thesystemisnowtenyearsolderandhasbeenthroughanumber

ofamendmentsbutinrealitynotmuchhasbeenresolvedWearenow

dealingwiththethirdincarnationofBillandthenumberofissues

thatarelivehasonlyincreasedInfactthevastmajorityoftheissues

thatwerelivetenyearsagoarestilllivetoday

 AllofthermZarekTaylorGrossmanHanrahanLLPTheauthorswishto

acknowledgetheirassociateDavidDinnerforsharingcontentandideasfrom

thetranscriptofhisforthcomingbookprovisionallyentitledT he ABCs of ABSin

providingassistanceontheretrospectivesectionofthispaperandthanktheir

associateTanyaZigomanisforherinvaluableassistanceinthepreparationofthis

paper

 EricKGrossmanTracyBrookeAnOverviewoftheStatutoryAccidentBenets

SchedulesinLawSocietyofUpperCanadaSpecialLecturesPersonalInjury

TorontoLawSocietyofUpperCanadaat

 Billinfra note

JGEKGCMK

Bywayofexampleweintroducedourarticlewithadiscus-

sionofthedenitionofaccidentintheaccidentbenetscontextgiven

thepivotalimportanceofthisterminaccessingentitlementtonofault

benetsInthedenitionhadrecentlybeentightenedtoonlyin-

cludeincidentsinwhichtheuseoroperationofanautomobiledirectly

causesdamageorimpairmentIntheinterveningtenyearswehave

seennoshortageofunusualsituationsgivingrisetoclaimsforstatu-

toryaccidentbenetsclaimswithverylilepredictabilityintermsof

outcome

InNovemberofhoweverthedenitionofaccidentnally

madeitswaybacktotheSupremeCourtofCanadawhichreleaseda

pairofdecisionsaddressingthedenitioninthetortcontextThesede-

cisionsoverturnedtwoOntarioCourtofAppealdecisionsaddressing

theissueofwhenaninjuryresultsdirectlyorindirectlyfromtheuse

andoperationofanautomobileandarguablymakeroomforapowerful

newapproachintheanalysisofwhenanaccidentisreallyanaccident

WhatisthenewapproachtakenCommonsense

Oncewemovepastthedenitionofaccidentandaccesstonofault

benetsisestablishedtherearestillamyriadofdicultiesindetermin-

ingentitlementtospecicbenetsWhilemanyofthesearelogistical

and relate to the various roadblocks facing claima nts and insurers as

theytrytocomplywiththeincreasinglyimpracticalproceduralrequire-

mentsoftheStatutoryAccidentBenetsScheduletherearealsoashock-

ingnumberofunansweredquestionsrelatingtofundamentalcoverage

issueseventhoughwearenowoveradecadeintotheBillera

For examplet he debatesur rounding the meaning of incurred

grindsonasdoestherelatedquestionofwhatproofisrequiredtodocu-

mentanongoingclaimforcareorotherservicesbeingprovidedbya

nonprofessional service providerThe role of the f undamental insur-

anceconceptofindemnityindeterminingaccesstocoverageisentirely

unclear

Thedenitionofwhatconstitutesacatastrophicimpairmentano-

tioncentraltotheongoingtradeobetweentheavailabilityoftortand

nofaultcoveragehasbeenstretchedbeyondallrecognitioncreatingan

openandverycostlyquestiononallclaimswhereanythingbeyonda

trivialinjuryisreported

 Ibid.s

 Citadel General Assurance Company v. VytlinghamSCCCitadelLumberm ens

Mutual Casualty Company v. HerbisonSCC

 StatutoryAccidentBenetsScheduleAccidentsonorAerNovemberReg

theSchedule

Accident Benefits

Where there are legitimate di erences of opinion regarding an in-

suredpersonsentitlementtoacertainbenetaccesstodisputeresolu-

tioniscompletelyonesidedProcedurallythereislileguidanceforan

insurerwhichdisagreeswithaDesignatedAssessmentCentreDACor

insurersexaminationmakingtheseassessmentspracticallybindingon

aninsurerwithnosimilarconstraintsonaninsuredpersonAninsurer

isessentiallyforeclosedfromobtainingasecondopinionwhenaprob-

lematicDACorinsurersexaminationhasbeenreceivedandthereaer

hasnowaytoinitiatedisputeresolutionwhereitwishestoobtaindirec-

tionf roma judge or arbitratorregarding itsongoing obligationsto an

insuredConverselyifaninsurerreliesuponaDACorinsurersexamina-

tionthatislaterfoundtohavebeenincorrectineitheritsapproachorits

conclusiontheinsurerfacesexposureforanyunpaidbenetsplusinter-

estplustheriskofaspecialawardandorextracontractualdamages

ThepasteighteenyearsofnofaultcoverageinOntarioalsohavenot

resultedinmuchheadwayincoordinatingvariouskindsofcoveragefor

lossofincomeinordertobringaboutfaireconomicrecoveryfollowing

amotorvehicleaccidentItremainsthecasethatdoublerecoveryis

easilyachievedwheremultiplepoliciesofinsuranceareavailablenot-

withstanding the r elativelyrecent amendme ntper miing the deduct-

ibilityofCanadaPensionPlanCPPbenetsfromincomereplacement

benetsAtthesametimewhereaninsuredsuersseveredisabilitybut

doesnothavetortrightsorcollateralbenetsnofaultcoverageiswoe-

fullyinadequatetomeetlifelongneeds

Inarelatedveinabsolutelynoeorthasbeenmadetoharmonizethe

operationofthe Sc hedulewiththeprovisionsoftheWorkplace Safety and

InsuranceActinordertopromotethefairandproactivehandlingof

claimsasseemstohavebeencontemplatedbysectionoftheSchedule

Insurerswhomakepaymentsingoodfaithwherethereisapotentialsec-

tiondefencearelewithnomechanismforcollectingonaWorkplace

SafetyandInsuranceBoardWSIBapprovedassignmentattheendof

thedayevenaerhavingpursuedlengthyandexpensiveproceedings

beforetheWorkplaceSafetyandInsuranceAppealsTribunalWSIATIn

contrastinsurerswhorefusebenetsonthebasisofsectionareoen

successfulinforcinginsuredstoactivatetheirWSIBclaimDespitethis

successtheburdenofproofisontheinsurertoestablishthattheperson

isentitledtoworkerscompensationbenetsunderanysuchplanwhich

wouldleadinsurerstoseekasectionWSIATdetermination

 SOcSchAWSIA

 Sumal v. American Home Insurance Co.OFSCDNoFSCOA

vardOFSCDNoSumal