Which came first: Accident notification, or the accident benefits application forms?

In a true chicken-and-egg argument, an Ontario man claimed his “reasonable explanation” for taking two years to inform his auto insurer about his injuries from a 2019 accident is because he never received the Application for Accident Benefits (OCF-1) form from his insurer.

Trouble was, the insurer never sent him the form, because he had not reported his injuries to the insurer, as noted in a recent decision from Ontario’s License Appeal Tribunal.

“I find the [claimant’s] explanation for the delay in notification, that he failed to receive the OCF-1 forms from [Economical Insurance], to be unpersuasive and illogical,” LAT adjudicator Tavlin Kaur wrote in a decision released Monday. “[Economical] could not have sent forms to the [claimant] if it was not made aware of the accident.”

The tribunal found Economical did not become aware of the claimant’s October 2019 accident until he submitted a completed application form for accident benefits on Sept. 27, 2021 — almost two years later.

Albert Adjetey was involved in an auto accident on Oct. 3, 2019, and sought accident benefits from his auto insurer, Economical.

Under Ontario’s Statutory Accident Benefits Schedule (SABS), once an insurer receives notice of a driver’s intent to apply for accident benefits, the insurer must provide the claimant with the appropriate OCF-1 forms, a written explanation of the benefits available, information to assist the person in applying for benefits, and other information related to the election of specified benefits. The insurer has 30 days to send the OCF-1 forms once it knows about the intent to apply for benefits.

SABS requires a driver to report any injuries to an insurer within seven days of the accident unless the person has a “reasonable explanation” for the delay.

Adjetey submitted his application for accident benefits two years after his October 2019 accident. Economical denied the claim, saying there was no “reasonable explanation” for the late application.

Adjetey acknowledged his application was late. But he contended Economical did not provide him with the OCF-1 forms; consequently, he was unable to decipher which accident caused his injuries, since he was involved in multiple accidents.

At first, Adjetey believed his injuries stemmed from two previous accidents. But as time progressed, it became clear his impairments were from the October 2019 accident, he told the tribunal. At that point, in 2021, he reported his impairments to his family doctor and retained legal representation. Economical did not provide him with the OCF-1 forms to make the application, he said.

LAT rejected Adjetey’s contention the delay was due to the insurer not sending out the OCF-1 forms. In addition to mentioning the circularity of this logic, Kauer wrote this was not actually mentioned as the “reasonable explanation” when Adjetey was examined under oath (EUO) in 2021.

“At the EUO, the applicant was asked about the delay in submitting the application,” Kauer wrote. “He never mentioned that [Economical] failed to provide him with the OCF-1 forms, or that he had in fact notified the respondent of the accident prior to Sept. 27, 2021.

“Rather, he stated: ‘I’m not sure why. I’ve never done something like this before, so maybe it’s because it’s my first time. So, when it comes to like application, the doctor, all these things, like I’m just getting my head wrapped around these things.’”

Kauer noted this wasn’t the first time Adjetey had been involved in an auto accident, implying Adjetey would have known the process for applying for accident benefits based on his previous experiences with auto injuries.

 

Feature photo courtesy of iStock.com/visualspace