Lost Educational Expenses

21(3)

Insured: furnish completed disability certificate

15 bus. days after receiving request from insurer [failing which no lost education expenses are payable until certificate furnished – s. 21(4)]

Death Benefit

26(1)(a)

Insurer: pay death benefit in respect of insured who dies as result of accident

180 days after accident

26(1)(b)

Insurer: pay death benefit in respect of insured who was continuously disabled as result of accident for 156 week period

156 weeks after accident

Notice of Intention to Apply for Benefits

32(1)

Insured: notify insurer of intention to apply for a benefit

7 days after circumstances giving rise to entitlement [failing which (if no reasonable explanation for failure) insurer may delay payment or determination until the later of 45 days after insurer receives application, or 10 bus. days after insured complies with s. 33(1) or (2) request – s. 32(10)]

Application for Benefits

32(5)

Insured: submit a completed and signed application for benefits to insurer

30 days after receiving forms from insurer

32(6)

Insurer: inform applicant that application form for benefits is incomplete or unsigned and indicate what is missing

10 bus. days after receiving incomplete or unsigned application

32(9)

Insured: submit an additional application if required by the insurer

30 days after receiving additional forms

Information from Applicant for Benefits

33(1)

Insured: provide information required to assess entitlement, statutory declaration, address and proof of identity

10 bus. days after receiving request from insurer

Failure to Comply with Time Limits

34

Insured: A person’s failure to comply with a time limit set out in Part VIII (Procedures for Claiming Benefits) does not disentitle the person to a benefit if the person has a reasonable explanation

Specified Benefits

35(1)

Insurer: notify insured of required election where insured may qualify for more than one of income replacement, non-earner or caregiver benefits

10 bus. days after receiving application [insured must make election within 30 days after receiving notice]

35(2)

Insurer: notify insured may re-elect caregiver benefit despite previous election in s. 35(1) if determined
insured suffered catastrophic impairment

10 bus. days of date of determination [insured must make election within 30 days after receiving notice]

36(4)

Insurer: either (a) pay the benefit, (b) notify insured of refusal to pay, reasons and advise of requirement
of s. 44 exam, or (c) make a s. 33(1) or (2) request

10 bus. days after insurer receives application and completed disability certificate [failing which insurer must pay specified benefit from date insurer received application to date insurer gives notice in s. 36(4)(b) – s. 36(6)]

36(5)

Insurer: either (a) pay the benefit, or (b) notify insured of refusal to pay, reasons and advise of requirement of s. 44 exam

10 bus. days after insured complies with s. 33(1) or (2) request [failing which insurer must pay specified
benefit from date insurer received application to date insurer gives notice in s. 36(4)(b) – s. 36(6)]

36(7)

Insurer: (a) provide copy of s. 44 report to insured and person completing disability certificate, and (b) provide notice of specified benefits it agrees and does not agree to pay and reasons

10 days after receiving s. 44 exam report

36(8)

Insurer: pay specified benefit if insurer determines insured is entitled to benefit where a s. 42 exam was conducted

10 bus. days after delivering notice in s. 36(7)(b)

36(9)

Insurer: pay income replacement benefit, non-earner benefit or caregiver benefit

at least once every 2 weeks (subject to any prepayment)

37(1)(a)

Insured: submit a further completed disability certificate on request by insurer determining continued entitlement

15 bus. days after receiving request from insurer [failing which no specified benefits payable for period between day 15 and day insurer receives completed disability certificate – s. 37(3)]

37(5)

Insurer: provide copy of s. 44 report to insured and person who completed disability certificate

10 bus. days after receiving s. 44 exam report

37(6)

Insurer: provide to insured notice of determination with amount of specified benefit it agrees to pay or refuses to pay, reasons and date of last payment

10 bus. days after receiving s. 44 exam report

Medical and Rehabilitation Benefits

38(8)

Insurer: notify insured of goods, services, assessments and examinations in treatment plan that insurer agrees to pay or refuses to pay and reasons

10 bus. days after receiving treatment and assessment plan

38(11)

Insurer: if no notice given under s. 38(8), insurer is prohibited from taking the position that insured has impairment to which Minor Injury Guideline applies, and shall pay for goods and services in treatment and assessment plan

for period starting 11th bus. day after day insurer receives application and ending on day insurer gives notice in s. 38(8)

38(13)

Insurer: provide copy of s. 44 report to insured and health professional who prepared treatment and assessment
plan

10 bus. days after receiving s. 44 report

38(14)

Insurer: notify insured re: what goods and services insurer agrees to pay, refuses to pay and reasons, determination re: Minor Injury Guideline and reasons

10 bus. days after receiving report

38(15)

Insurer: pay for goods and services agreed to in notice under s. 38(8) or (14) or is required to pay

30 days after receiving invoice

39(2)(c)

Insurer: pay for medical or rehab. expenses for which insurer has notified insured it will pay without submission of a treatment and assessment plan

30 days after receiving invoice

Minor Injury Guidelines

40(2)

Claimant: submit a treatment confirmation form

time specified in applicable Minor Injury guideline

40(3)

Insurer: send notice to claimant and health practitioner acknowledging receipt of treatment confirmation
form and advising if claimant is an insured person with respect to accident

5 bus. days after receiving treatment confirmation form

40(4)

Insurer: pay each invoice for goods/services in s. 15 or 16 provided in accordance with Minor Injury Guideline
if claimant submits application under s. 32

30 days after receiving invoice for goods and services

41(2)

Insurer: pay expenses in notice to insured who submits s. 32 application

30 days after receiving invoice

Attendant Care Benefits

42(3)

Insurer: provide notice to insured advising which expenses the insurer agrees to pay and reasons

10 bus. days after receiving assessment of attendant care needs

42(6)

Insurer: pay attendant care benefits, and pending receipt of s. 44 report, calculate amount based on assessment of attendant care needs

10 bus. days after receiving assessment of attendant care needs

42(7)

Insured: provide to insurer assessment of attendant care needs so insurer can determine continued entitlement
to and amount of attendant care benefits

15 bus. days after insured receives notice requesting assessment of attendant care needs

42(13)

Insurer: provide to insured and person who prepared assessment insurer’s determination re: what attendant care benefits and expenses insurer agrees and refuses to pay for, reasons, and copy of s. 44 exam report

10 bus. days after receiving s. 44 exam report

42(15)(c)

Insured: provide a reasonable explanation for non-compliance with s.44(9) for reconsideration of application once insured subsequently complies

within 10 days of failure to comply

42(16)

Insurer: provide to insured notice of determination that insured is not entitled, by reason of s. 20, to attendant care benefits beyond 104 weeks after accident, and reasons therefore

not less than 10 bus. days before date of last payment of benefit

Parts IV & V Expenses & Benefits

43(1) & (2)

Insurer: pay death, funeral or Part IV benefit, or provide notice of refusal to insured with reasons

30 days after receiving application for benefits

Insurer’s Exams (s.44 exams)

44(6)

Insurer: provide notice to insured under s. 44(5) of s. 44 exam, including date, time, location, reasons
for exam, type of exam, whether attendance necessary and info. re: conductor of exam

not less than 5 bus. days before exam unless otherwise mutually agreed

44(7)

Insurer: provide notice to insured advising of change in type of exam, requiring attendance, advising of
date, time and location of exam (where previous notice was given to insured indicated attendance not required, but conductor
of exam requires attendance)

at least 5 bus. days before examination

44(9 para.1)

Insurer & Insured: if attendance is not required, provide to person(s) conducting exam all relevant
prior test and exam results, documents and other information necessary for review of insured’s medical condition

5 bus. days after notice of s. 44 exam received by insured [failing which possible sanctions depending on the reason for the s. 44 exam – see ss. 37(7), 42(14)]

44(9 para.2)

Insurer & Insured: if attendance is required, provide to person(s) conducting exam all relevant prior test
and exam results, documents and other information necessary for review of insured’s medical condition

not later than 5 bus. days before scheduled exam

Catastrophic Impairment

45(3)

Insurer: provide to insured notice accepting or denying catastrophic impairment and notice requiring s. 44
exam

10 bus. days after receiving application fo determination of catastrophic impairment

45(5)

Insurer: provide to insured and person who prepared application insurer’s determination and reasons re: catastrophic impairment, and copy of s. 44 exam report

10 bus. days after receiving s. 44 exam report

Payment of Benefits

46.2(2)

Provider of Goods or Services: to provide insurer information required to assess liability for payment of goods/services

within 10 days of request for info by insurer

46.3(2)

Insured: to provide insurer information requested regarding invoice submitted for goods/services

within 10 days of request for info by insurer

Explanation of Benefit Amounts

50(4)

Insurer: deliver benefit statement if amounts in s. 50(3) have changed from previous statement

once a year, commencing not later than 12 months after determination of catastrophic impairment, or once every 2 months, commencing not later than 2 months after application for benefits made

Repayments to Insurer

52(3)

Insurer: provide notice of amount required to be repaid and possibility of deduction from income replacement
or caregiver benefit if applicable

within 12 months after payment made [failing which, the insured is not required to repay unless it was originally paid as result of wilful misrepresentation or fraud]

Time Limit for Proceedings

56

Insured: An application to the License Appeal Tribunal under s 280(2) in respect of a denied benefit

within 2 years after insurer’s refusal to pay the amount claimed [note: the court has confirmed that this limitation period is subject to the discoverability rule: see Tomec v. Economical Mutual Insurance Company, 2019 ONCA 882].

Responsibility to Obtain Treatment, Participate in Rehab, Seek Employment

57(5) & 58(4)

Insurer: notify insured of its intention to stop payment of income replacement, non-earner, or caregiver benefits for failure to obtain treatment, participate in rehabilitation, or make efforts to return to employment

payments may cease after 10 days have elapsed from insurer’s notice if insured fails to comply

Notices & Delivery

64

For general rules regarding the computation of time, modes of service, deemed delivery dates, etc. see s.64 in its entirety