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t heLawSocietySpecia lLectures

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

cidentbenetsr egime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t herealmof accidentbenetsthathad yettoreceiveadjudica-

tiveinterpretation

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

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

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

thatare live hason lyincreas edIn factt hevast majority ofthe issues

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

 AllofthermZa rekTaylorGrossmanHanraha nLLPTheauthorswishto

acknowledgetheiras sociateDavidDinn erforsharingcontentandidea sfrom

thetransc riptofhisforthcom ingbookprovision allyentitledT he ABCs of ABSin

providingassist anceontheret rospectivesec tionofthispaperandt hankthei r

associateTanyaZigomani sforherinvaluableassista nceinthepreparat ionofthis

pape r

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

SchedulesinLawSocietyofUpperCa nada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 discu s-

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

thepivotali mportanceof thistermin accessingent itlement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a nautomobiledirectly

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

seen noshortage of unusual situations givi ngr ise toc laims forst atu-

toryaccident benetsc laimsw ith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whic hreleased a

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

cisionsoverturnedt woOntario Court ofAppeal decisionsaddressing

theissueofwhena ninjuryre sults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 logistica l

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

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

mentsoft heStatutoryAccidentBe netsSchedulethereare also ashock-

ingnumberofuna nsweredquestionsrelati ng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s ervices being providedby a

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

anceconceptofindemnit yindetermin ingaccesstocoverageisenti rely

unc le ar

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

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

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

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

trivialinjur yisreported

 Ibid.s

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

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

 StatutoryAccidentBenetsSc hedule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cer tain benetaccess to disputeresolu-

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

insurerwhichdisagreesw ith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esse ntiallyforeclosedfrom obtain ing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obt ain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acc ident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Ca nadaPensionPlanCPPbenetsf rom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t he Sc hedulewith theprovi sionsof theWorkplace Safety and

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

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

Insu rers whomak epayme ntsi ngood faith wheret here isapo tent ialse c-

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

Safetya nd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