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Friday, July 31, 2015
Failure to Submit Disability Certificate Disentitles Claimant to Accident Benefits
A recent arbitration decision confirmed the importance of a disability certificate in accident benefits cases.
In Anthonipillai v. Security National, FSCO A11-001168 (July 12, 2013), the applicant was injured in an accident on April 21, 2008. Although the insurer requested she submit a completed disability certificate several times, she failed to do so until 3.5 years after the accident, after an arbitration pre-hearing. Even when she did submit a disability certificate, it only addressed caregiver benefits and not housekeeping. The applicant argued that by continuing to adjust the claim and pay benefits, the insurer waived the requirement for a disability certificate.
The Arbitrator held that the applicant was disentitled to housekeeping and home maintenance benefits as she never submitted a disability certificate. The insurer did not waive the requirement for a disability certificate as it had an obligation to adjust the claim, even if the plaintiff had not complied with her obligation. In addition, the treatment and assessments the insurer adjusted were applied for through OCF 18 and 22 forms, which contain the signature of a health professional confirming the information is accurate, the treatment reasonable and necessary and acknowledging that it is an offence to make a false statement. The insurer was entitled to insist on the same assurances through a disability certificate relating to caregiving and housekeeping expenses. In addition, the insurer was entitled to obtain s. 42 assessments, without being deemed to have waived compliance by the insured.
