Section 32(5) of the Statutory Accident Benefits Schedule (SABS) prescribes a 30-day timeline by which an applicant must submit their Application for Accident Benefits (OCF-1) to their insurer after receiving the application forms. This deadline is strict and may bar an applicant from proceeding with their claim if not met, as seen in a recent LAT decision.
The Accident and Late Application
In Sheikh v TTC Insurance, the applicant was involved in a motor vehicle accident on August 25, 2022. On September 12, 2022, the respondent insurer, TTC Insurance, sent the applicant an OCF-1 to complete. The applicant submitted the OCF-1 to the respondent insurer on February 21, 2023, approximately five months after receiving the application forms. The respondent insurer asked for a reasonable explanation for the delay in submitting the OCF-1. The applicant’s representative advised that the delay was because the applicant did not believe her injuries required medical treatment at the time of the accident, but her symptoms later became worse, requiring medical intervention. On June 16, 2023, the applicant attended an Examination under Oath where she stated that her symptoms began shortly after the accident.
Definition of “reasonable explanation” in the SABS
Section 34 of the SABS states that a person’s failure to comply with the 30-day timeline does not disentitle them to a benefit if they have a reasonable explanation. An explanation must be determined to be credible or worthy of belief before its reasonableness can be assessed, and the onus is on the insured to establish a “reasonable explanation”. Ignorance of the law alone is not a “reasonable explanation”, nor does a lack of prejudice to the insurer make an explanation automatically reasonable. The “reasonable explanation” test is both subject and objective, considering both personal characteristics and a “reasonable person” standard. Finally, an assessment of reasonableness will balance the prejudice to the insurer, the hardship to the claimant, and whether it is equitable to relieve the insured of the consequences of their failure to comply with the timeline.
Adjudicator finds no “reasonable explanation”, therefore, no accident benefits
The adjudicator found that the applicant’s explanation was not reasonable, because the medical evidence indicated that the applicant’s impairments required medical treatment shortly after the accident and not a few months later. The applicant’s statements during the EUO, as well as the medical records, showed that the applicant attended at the Medical Urgent Care and at Mackenzie Medical Rehab Centre Inc. shortly after the accident, complaining of body pain, neck pain, lower-back and mid-back pain, leg pain, shoulder pain, and headaches. As such, the adjudicator found it “difficult to reconcile the applicant’s statement that she did not believe her symptoms were serious enough with the information in the medical records”, especially while she was seeking and receiving treatment during the five months that she claims her impairments were not serious enough to complete the OCF-1. Given that the applicant did not provide the Tribunal with a reasonable explanation, she was not relieved against the consequences of her failure to act and was barred from proceeding with her application.
Takeaways
The SABS has strict timelines that, if not complied with, could bar an applicant from receiving accident benefits. In this, case the applicant was barred from proceeding with her claim because she did not have a reasonable explanation for submitting her OCF-1 to the insurer after the 30-day timeline.
See Sheikh v TTC Insurance Company Limited, 2025 CanLII 49179 (ON LAT)