All disputes concerning entitlement to accident benefits are governed by scheme

Automobile insurance

All disputes concerning entitlement to accident benefits are governed by scheme

Dispute resolution process under Insurance Act. Insured W was injured during incident when garage door fell on him after moving vehicle out of garage. Insurer A Co. denied insured’s application for accident benefits on ground that incident was not “accident” as defined by s. 3(1) of Statutory Accident Benefits Schedule (SABS). Insured applied for mediation as contemplated by dispute resolution process scheme under s. 279 of Insurance Act. Insurer brought application for determination of whether insured was involved in “accident” as defined by s. 3.1 of SABS on basis that it was preliminary issue that had to be determined before scheme applied. Application judged dismissed application. Judge held that scheme governed all disputes concerning entitlement to accident benefits, including whether claimant was involved in accident and qualified as insured person under SABS. Judge found that this was not appropriate case for application. Insurer appealed. Appeal dismissed. Judge was correct in holding that it governed all disputes concerning entitlement to benefits, including whether claimant was involved in accident. Scheme established comprehensive alternative process to courts. While court proceedings might provide more expeditious process where it was determined claimant did not qualify as insured person, court proceeding would be duplicative where claimant did qualify as insured person. Having regard to purposes of Act and scheme, “insured person” as it appeared in scheme can reasonably be read as encompassing all persons claiming entitlement to benefits under SABS whether or not it was ultimately determined that they were entitled to benefits.
Ayr Farmers Mutual Insurance Co. v. Wright (2016), 2016 CarswellOnt 16494, 2016 ONCA 789, Simmons J.A., E.E. Gillese J.A., and C.W. Hourigan J.A. (Ont. C.A.); affirmed (2015), 2015 CarswellOnt 15632, 2015 ONSC 6219, P.R. Sweeny J. (Ont. S.C.J.).