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LTD The Year in Review
Steve Rastin
McCarthy Bergeron Rastin Clifford LLP
Box 398 16984 Hwy 12
Midland ON L4R 4L1
Tel 705 528 7088
Fax 705 528 7067
OTLA 2005 FALL CONFERENCE
LTD THE YEAR IN REVIEW
TEN THINGS YOU OUGHT TO KNOW
By Steve Rastin and Lee Ann FournierMCCARTHY BERGERON RASTIN CLIFFORD LLP
As the Ontario workforce ages there is a significant likelihood that the number of
workers finding themselves disabled and claiming LTD benefits will increase
Recent proposals to raise or eliminate the mandatory retirement age may also
contribute to this trend Plaintiffs lawyers will likely encounter more disgruntled
workers complaining of being wrongfully denied long term disability benefits Its
simple mathematics More claims will lead to more disputes In an era when
legislative changes increasingly impair the ability of motor vehicle accident
victims to obtain full compensation lawyers may find that LTD litigation naturally
becomes a larger part of their practice
LTD litigation remains dynamic Ten years ago jury notices were barred in LTD
actions in Ontario now they are common1
The doctrine of bad faith has taken
root in LTD litigation Insurers are constantly developing new and innovative
arguments which have the potential to defeat a Claimants action for benefits
Tactics and strategy are essential weapons for the Claimant and his her lawyer
as they cross blades with some of the largest insurers in Canada in these
disputes
IM Steven Rastin Judge or Jury Where to Turn for Insurance Claims 1998 OTLA Spring Conference
Day II Tab 2 and Ramm v Sun Life Assurance Company ofCanada 1999 43 O R P 652 Gen Div
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With this in mind we have set out a few recent developments that Plaintiffs
lawyers might find useful as they litigate in this area
Procedural Issues
The Impact of the Pre Claim medicalexamination
Pursuant to the Rule 33 01 of the Rules of Civil Procedure and s 105 of the
Courts of Justice Act a defendant is entitled as of right to compel the plaintiff to
submit to a medical examination However what is the impact of medical
examinations conducted prior to the issuance of the Statementof Claim It is not
uncommon for insurers to require regular medical examinations while a person is
on claim When a claim is denied insurers have generally placed the onus for
gathering additional medical information on the claimant at his her expense
A common exception to this practice seems to occur after the insurer becomes
aware that the claimant has retained counsel and is considering litigation It is
our common practice to write a letter asking for the file before suing This allows
us to evaluate the file and to determine if there is any evidence of improper
conduct that should be specifically pleaded in the Statement of Claim In some
cases however LTD insurers have responded to a request to produce the file by
sending the Claimant to another round of medical examinations If the
examinations support disability benefits are reinstated and the insurer avoids
litigation
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If benefits are not reinstated LTD insurers will routinely schedule another round
of medical examinations Be advised however that Zinchuk v Unum
Providentof Canada2
stands for the proposition that a second round of medical
examinations should not be granted In this case Zinchuks mental health was in
question In this case Unum conducted three psychiatric examinations in 1996
1999 and 2002 Benefits were terminated shortly after the last examination and
the Statement of Claim was issued in 2003 Unum relied on Tsegay v McGuire3
which allowed a fresh examination after a tort action was started notwithstanding
that the defendant had conducted two examinations prior to issuance of the
claim However Master Egan preferred to follow a line of cases flowing from
Binns v Skinner Estate4 where Justice MacDonald refused to allow the same
insurer to have separate examinations for accident benefits and statutory third
party purposes MacDonald J stated
I am of the view therefore that a prior medical examinationunder one
statute or its regulation is relevant to the question of whether a
medical examination properly may be ordered under the other statute
or its regulation 5
Masters and Judges seem wary of allowing insurers to bolster their case when
they have already had the benefit of choosing to send a Claimant to the doctor of
their choice and to make a decision regarding payment of benefits based on that
2 February 2 2005 Master J Egan Court File No 03 CV 251214CM CanLII 2327 Ont S C3
2000 1 C P C 5th 311 Ont S C J4
2000 O J No 3739 S C J5
at para 14 See also St Pierre v Liberty Mutual Insurance Group 2001 O J No 5973 affirmed on
appeal at 2002 O J No 5356 S C J and Ebrani v Citadel General Assurance 1998 O J No 6279
Gen Div
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examination While the Zinchuk decision is clearly beneficial to claimants this
matter is far from decided
The Choice of who to Examine of Behalfof the Insurer
This is a critical decision Many LTD insurers have professional witnesses who
travel the country appearing as the representative of the defendant at
Examinations for Discovery These witnesses will have no direct experience with
the file or your client Generally speaking examining these witnesses is of
limited value If you have a legitimate bad faith case examinations of this sort
are a complete waste of time
My practice is to require a sworn Affidavit of Documents with Schedule A
productions BEFORE I advise the insurer of the person I want to examine LTD
insurers are usually good about providing you with internal correspondence We
try to identify the lowest decision maker on a file that had a significant role in the
decision to terminate benefits Examination of the decision maker may give you
first hand information that you would never obtain by examining the insurers
professional witness For example a couple of years ago after reviewing the
production documents we determined that the decision maker on a file was a
claims representative based out of Florida I required that she be produced in
Canada and under examination she admitted that she had a grade 12 education
no medical training no training manual no understanding of Canadian law no
knowledge of what CPP disability was had never met my client and did not
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bother to even schedule a medical before terminating benefits because we dont
do that down in Florida
Asking the insurer to produce the decision maker may also assist you in
determining whether the LTD insurer has farmed out the file to a claims handling
company This practice which has only recently come to light involves
situations in which large Canadian insurers have contracted with independent
companies usually American to assist and or take over claim handling of some
files Clients have complained that the claims handling practices in some of
these cases have been very aggressive A warning bell should sound if you are
told that the decision maker is not an employee of the insurance company
Claims handling is a high turn over industry and the adjuster may have left
however the adjuster may NEVER have worked for the LTD insurer in the first
place You need to determine if that is indeed the fact If necessary find out
the identity of the independent claims handling company and add it as a party to
your action
OTLA member John Johnson has more experience with this phenomenon than
most and Plaintiff lawyers that are interested in this area should contact John or
see some of the papers he has delivered at recent Bad Faith Section
Conferences
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The Option to Bring an LTD Action in Simplified Rules
One of the ongoing barriers to LTD litigation is that the quantum of the claim is
often not significant by the date of trial Assuming you are retained shortly after
benefits are terminated and you move the action forward quickly total arrears by
the date of trial might be very modest We have personally seen cases where
there has been a CPP overpayment and the total arrears at the eve of trial has
been less than 15 000 While the value of future benefits may be significant
that is only relevantfor the purpose of settlement discussions A Court can only
order payment of arrears From a cost benefit analysis perspective it can be a
challenge for lawyers and clients
One possible solution flows out of the recent decision of Keddy v Clarica Life
Insurance Company 6In this case the Plaintiff sued for benefits from the date
of termination to the date of trial plus damages for breach of contract mental
distress and or aggravated damages The twist is that she sued in Simplified
Rules Clarica brought a motion to amend its pleadings and claim that the action
was not within the jurisdiction of Rule 76 and ought to be transferred to ordinary
procedure Clarica wanted inter alia an Examination for Discovery Clarica
noted the claim was for more than 50 000 and complained that the strategy
adopted by the Plaintiff would likely lead to multiple proceedings Mrs Keddy
responded by abandoning the amount of her claim exceeding 50 000 Justice
Browne refused to move the claim out of Simplified Procedure He found that
6November 13 2002 Justice E R Browne Court File No 38656 CanLII 10004 Ont S C
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any future litigation about future benefits would be based on evidence that would
come into being at a later date and should not bar the current matter from
proceeding in its current format
There are some significant advantages in some cases to being able to get a case
to Court quickly without having to go through the expense of Examinations for
Discovery This strategy is probably not the best however in cases where the
Claimant feels that he she has a legitimate bad faith or poor claims handling
argument In those cases Plaintiffs lawyers will need the opportunity to examine
the insurer in order to build the case
Collateral Deduction Disputes
Long Term Disability contracts are always written by the insurer and the insured
has usually never seen a copy of the contract This is especially true where the
LTD policy is part of a workplace group benefits policy It is not surprising that
these contracts tend to contain very favourable terms for the insurer Care
should be taken when interpreting the collateral deductions clause of the
contract Generally the insurer takes the position that it is entitled to any income
paid to the worker from any source including but not limited to C P P disability
benefits wages severance packages other insurance policies etc
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It is worth noting that some insurers based outside of Ontario have often taken
the position that they are entitled to deduct payments made to MVA victims for
income replacement benefits paid pursuant to accident benefits provisions of
policies In the alternative the insurer will write the victim a letter demanding that
he she advance a subrogated claim for repayment of those benefits from the
accident benefits or tort insurer Claims of this nature arise from a
misunderstanding of the Ontario Insurance Act In these cases our practice is to
send them a copy of Section 267 8 which clearly sets out Ontario law which
requires the LTD insurer to pay first It is the motor vehicle insurer which gets the
benefit of LTD insurance and not the other way around
WSIB Benefits
LTD insurers will also try to get the benefit of WSIB coverage As a general rule
a person opts for either WSIB benefits or LTD benefits Even if entitlement to
LTD benefits survived the election for WSIB payments the WSIB quantum would
likely wipe out any obligation on the LTD insurer to pay An important case
dealing with the interaction between WSIB money and LTD payments is
Abdulrahim v Manufacturers Life Insurance Company 8Here the Plaintiff
was seriously injured with a cutter and sustained injuries to his arm and leg He
originally opted to receive WSIB benefits and he also applied for LTD benefits
through his Group Policy ManuLife took the position that it was entitled to an off
7R S 0 1990 1 8
82003 65 O R 3d 543 2003 CanLII 48161 Ont S C
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set for any WSIB money paid The Plaintiffs solicitors then wrote to the parties
advising everyonethat they had decided to de elect WSIB benefits and wanted
to proceed with a tort action against the German based manufacturer of the
cutter that injured Abdulrahim WSIB demanded full repayment by certified
cheque and discontinued payments in the interim Manulife strongly objected to
the Plaintiffs decision and argued that the Policy obligated Abdulrahim to apply
for benefits to which he was entitled including WSIB and his decision to de elect
was improper Manulife attempted to deduct the money that would have been
paid by WSIB and relied on a section of the policy which stated
If an Employee does not apply for a benefit for which he is eligible the
amount of such benefit will be estimated by Manulife Financial andassumed to be paid 9
The central issue at the motion was the proper interpretation of the phrase
receives or is entitled to receive in the Policy Justice Himel applied the
principles of interpretation relating to insurance contracts as set out by Mr
Justice Sopinka in Brissette v Westbury Life Insurance Company 10These
principles include the idea that ambiguities should be construed against the
insurer After a lengthy analysis he concluded that the contract was not clear
and should be interpreted in favour of the insured He found that since the
Plaintiff elected to proceed in tort the WSIB benefit was not availableto him
9Para 17 of decision clause g ofBenefit Calculation Rules
11992 CanLII 32 S C C 1992 3 S C R 87 at 92 93
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Deducting Severance Payments from LTD Payments
Most LTD contracts stipulate that they are entitled to deduct money paid by the 410employer to the employee by way of severance Employers on the other hand
have tried to claim a set off for LTD payments when paying out severance
packages It is very common for employers to terminate workers that have been
off for an extended period of time with or without a severance Plaintiffs lawyers
running LTD actions will almost certainly be asked to provide advice on the inter
action between LTD payments and severance packages
Employers have been trying to deduct LTD payments from severance package
for a considerable period of time The Supreme Court of Canada seemed to
support their position in Sylvester v British Columbia when the Supremes
allowed the employer to take credit for disability payments and deduct those
payments from damages for wrongful dismissal Justice Major found that since
the disability policy was entirely funded by the employer there was no
expectation that the employee could receive both benefits
I
There was significant criticism to Sylvester as many felt that the Courts were
making it all too easy for employers to terminate ill employees at reduced cost
The potential harm caused by Sylvester was greatly limited by the Ontario Court
1997 146 D L R 4th 207 S C C
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of Appeal in Sills v Childrens Aid Society of Belleville12 Simmons J A
relying on an earlierdecision of the Supreme Court13 concluded
Absent an express provision precluding double recovery in my view
the principles in Cunningham assist in determining whether an
intention that there would be double recovery in the event of a
wrongful dismissal can be inferred I consider it reasonable to assume
that an employee would not willingly negotiate and pay for a benefit
that would allow her employer to avoid responsibility for a wrongfulact I consider it reasonable to infer that parties would agree that an
employee would retain disability benefits in addition to damages for
wrongful dismissal where the employee has effectively paid for the
benefits in question 14
The key here is to note that benefits can be paid for directly OR INDIRECTLY
Since most employees can argue that they take less to have their group benefits
paid for by the employer it can be said to be an indirect benefit These principles
have been followed repeatedly in Ontario See for example the recent decision
of Dowling v TNTLogistics North America 15
What about the reverse LTD insurers claim they are entitled to severance
packages Their contracts often state this specially However recent authority
suggests that they may not be on solid ground Consider for example the
closing statement of Speigel J in Dowling
There is nothing in the employment contract that would indicate that
Dowling cannot receive both employment benefits and LTD benefits
Further the provisions of the Plan are contractual provisions with the
insurer not with TNT There are the usual provisions that state that
an employee on LTD has his or her benefits reduced if an employee is
122001 53 O R 3d 577 C A
13 Cunningham v Wheeler 1994 CanLII 120 1994 1 S C R 35914
At para 4515 May 24 2004 Justice G Speigel 2005 CanLII 18293 Ont S C
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earning money elsewhere I do not interpret these provisions toapply to an employee receiving damages for wrongful dismissalan insurer under an LTD policy would be hard pressed to deductthese damages 16
Until recently the question of how to treat severance packages was rare
because most employers use the doctrine of frustration to terminate contracts
without paying severance However employers should be aware of the recent
Ontario Court of Appeal decision of 0 N A v Mount Sinai Hospital17 which
holds that notwithstanding the exemptions set out in the Ontario Employment
Standards Act an employer MUST pay severance to an employee even if the
contract is frustrated
Entitlement Issues
Denial basedon Failure to Mitigate
Winning in LTD litigation is about more than proving your client is disabled
according to the terms of the policy LTD litigation seems simpler than motor
vehicle cases because you dont need to worry about liability questions There
are a host of arguments however that an insurer can raise to deny liability It is
necessary to anticipate and counter these arguments as early as possible in the
litigation process
16Para 13 emphasis mine
172005 O J No 1739 C A
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Some concerns are common to all personal injury litigation For instance in
Deyonge v Liberty Mutual Insurance Company 18 the trial judge found that the
plaintiff was someone who was quite sick however he also found that she had
failed to seek sufficient medical treatment He concluded on the evidence that
she would have recovered earlier if she had sought psychiatric assistance as per
her doctors recommendation He reduced the allowable period of her disability
accordingly When mitigation arguments are in play it is essential that you be
able to argue with supporting medical evidence that 1 the proposed treatment is
unrealistic or doctors think it is a bad idea 2 that your client has tried a form of
the treatment without success already 3 that the treatment will not cause
improvement in any event and or 4 that your client has taken all reasonable
steps to assist with his her own recovery Failure to cover off mitigation may
result in a claim being dismissed even when the Court finds the client is disabled
Denial basedon Misrepresentation
Another area of particular concern in LTD contracts is misrepresentation
Insurers have relied upon failure to disclose and misrepresentation to deny
numerous claims Consider the leading Court of Appeal decision of Gregory V
Jolley Aetna Life Insurance et al19
In the case Gregory asserted a claim for
disability benefits and was successful after a 19 day trial notwithstanding that the
trial judge found he had misrepresented material facts relating to his medical
182003 25 C C E L 3rd 27 2003 CanLII 42935 Ont S C affirmed at 2004 CanLII 30220 Ont C A
192001 54 O R 3d 481 201 D L R 4th 729 147 O A C 336 Ont C A
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condition and income The trial judges decision was based on his conclusion
that there was no evidence of fraud and therefore the incontestability clause
applied This clause which is common to most policies holds that an insurer
cannot void a policy for misrepresentations after two years from the application
for insurance in the absence of fraud The decision was overturned by the
Ontario Court of Appeal which found that Gregory had misled the insurer with
respect to his medical conditions and had grossly overstatedhis income He was
in fact losing money not making the six digit income he claimed The Court found
that the misrepresentations were sufficiently reckless as to be considered
fraudulent in the civil sense The result of the insureds failure to disclose
material facts or act in good faith therefore made the policy voidable and Aetna
was not obliged to pay any benefits even though Gregory was clearly profoundly
disabled
Material misrepresentation is routinely pleaded by insurers In cases where
clients have filled out an application for insurance which will likely not happen in
group policy situations counsel should get a copy of the application early in the
process and go over the form with the client line by line to look for any possible
inaccuracies Remember that innocent mistakes are treated differently at law
than fraudulent misrepresentations
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Limitationand Qualifvina PeriodIssues
Often LTD insurers will provide a relative short appeal window when they set out
a denial letter Many letters typically give claimants 60 or 90 days to appeal
failing which the insurer will close its file We have had several instances where
claimants for whatever reason dont take action within this appeal window and
then conclude that they have missed the opportunity to appeal the decision to
deny benefits In some cases claimants will wait months if not years before
consultinga lawyer
If you are consulted by a claimant it is important to actually see a copy of the
denial letter The stated appeal window on the letter is not determinative but
unless you have evidence to the contrary you should assume that you are
governed by the standard one year limitation period
It is important to get a hold of the termination letter because some policies have
extended notice periods We have encountered one large insurer that regularly
incorporates a two year appeal period 20
Even if a client has missed the limitation period Morgan v Dominion21 is the
root case in a long line of authority that stands for the proposition that benefits
cannot be denied until they become due and claimants therefore have a rolling
20The Great West Life Assurance Companyof Canada21
1980 31 O R 2d
285 H C J
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limitation period in which to claim benefits If a potential client comes into your
office after the expiry of a limitation period it is important to immediately issue a
Notice of Action to preserve the claim to as much of the arrears as possible
In situations where the client has improved over time however Morgan v
Dominion may not be able to help you In order for a client to qualify for benefits
it is necessary to prove that he she was disabled during what is commonly
referred to in policies as the qualifying period It is not enough to prove that
your client is disabled as for the date of trial you must also prove that he she
was disabled as of the end of the qualifying period Consider for example
Lyons v Canada Life Assurance Company22 where the jury awarded the
Plaintiff six months worth of disability benefits covering a six month period in
1995 even though the claim was not commenced until November 1998 The
Court of Appeal overturned the award primarily on the basis that an award for
benefits for this time period was barred by the limitation period in the policy 23
Plaintiffs counsel attempted to defend the decision using the discoverability
principle but that argument was doomed to failure because the trial judge did not
reference discoverability in his charge to the jury
222002 22 C C E L 3d 217 2002 166 O A C 299 CanLII 18089
23The Court also overturned the award of 235 000 aggravatedand 25 000 punitive damages
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A better example of the qualifying period piffall at work is Martin v
Manufacturers Life Insurance Company 24Martin injured herself in a ski
accident in April 1998 She did not submit a claim until October 2001 and it was
denied in January 2002 due to late filing In June 2003 she commenced an
action Justice Bouck conducted a detailed analysis of the policy and concluded
that Martin was obligated to file a claim within a specified period of time after the
injury Further to succeed she needed to prove that she was totally disabled
from working within the qualifying period In Martins case the evidence showed
that she was not disabled during the qualifying period but only became disabled
later when she ceased working in order to undergo surgical treatment However
this later period of disability was found irrelevant Because there was insufficient
proof that Martin was disabled during the qualifying period the claim was
dismissed
The risk of being found to have become disabled after the end of a qualifying
period is significant especially in cases where individuals are suffering from
degenerative problems have been terminated from their employment and do not
seek legal advice for an extended period of time after benefits are denied
24 August 2004 Bouck J 2005 BCSC 528 CANLII
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lniunctive Relief
Perhaps the most intriguing case to come out of LTD litigation in recent years is
the motions decision of Traynor V Unum Life insurance Company of
America25
After developing chronic fatigue syndrome Andrew Traynor applied
to Unum for disability benefits but he was denied Traynor not only launched a
Statement of Claim but also brought an immediate motion for an interlocutory
mandatory injunction to require Unum to pay monthly disability benefits pending
trial Significant evidence was led concerning bad faith claims handling practices
by Unum The motion was granted at first instance but overturned on appeal to
the divisional court in a sharply divided decision
Justices Cunningham and Matlow issued a terse four page decision allowing the
appeal The majority was clearly concerned with the floodgate argument noting
that mandatory interlocutory injunctions are exceptional relief granted only in
exceptional circumstances and that if this were such a case similar results
might be held to constitute irreparable harm in a broad variety of breach of
contract cases even outside of insurance policies a result which is not
supportable by the present state of the law The majority also concluded that it
could not be said that Traynor would suffer irreparable harm if the injunction was
not granted Finally the majority found the ruling would wrongfully deprive Unum
252003 65 O R 3d 7 2003 CanLII 40149 and 17998 Divisional Court
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of the right to require sufficient proof in order to continue payments as entitlement
to future payments without proof was not a benefit conferred by the policy
Justice Kurisko wrote a spirited dissent supporting the ruling of the motions
judge He found ample evidence of irreparable harm and further found that
Unums conduct was so blameworthy that the insurer could not be said to be
coming to Court with clean hands and its own actions should disentitle it to relief
Kurisko J relief in part on the ruling of Keenan J who even though he granted
leave to appeal ordered continuation of disability payments pending the appeal
He said
I have concluded however that it would be manifestly unfair to Mr
Traynor to permit Unum to withhold payments under the insurance
policy pending the outcome of this matter At this point there appearsto be responsible medical evidence that he suffers form chronic
fatigue syndrome Without the payments under the policy Mr
Traynor would be reduced to a level below the level of poverty His
circumstances would be such that he would not even be able to afford
food for himself and his family because of all the other obligations that
he confronts each month 26
Justice Kuriskos decision is extensive and supported by considerable authority
While the decision of the majority is clearly a significant obstacle the dissent at
least leaves open the possibility that the law will evolve in this direction in the
future
26Dissent ofKurisko J paragraph46 quoting Keenan J
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The Growth of Bad Faith in LTD Litigation
Considerable attention has been given to the development of the bad faith
doctrine in fire loss and accident benefits cases but a good argument can be
made that bad faith and aggravated damages claims will likely be more
successful in LTD litigation than anywhere else In house lawyers at the large
disability insurance companies are very aware of recent bad faith decisions
Further there is increasing evidence that Canadian insurers are being influenced
by American claims handling practices which have historically been highly
aggressive Some Canadian companies have farmed out difficult claims to
American Claims Handling companies Mergers and competitive business
practices have put increasing pressure on claims handlers In the United States
questionable claims handling practices have resulted in large damage awards
and significant fines27
Lawyers for LTD insurers seem prepared to accept that aggravated and bad faith
damages are appropriate in some cases provided supporting evidence is
tendered and they will settle cases on that basis28
27Consider the precedent setting fine of 1 million US imposed against Unum Provident as a result of the
Georgia Insurance Commissioners investigationof its practices28
For judicial confirmation of same see Bryan v Crown Life Insurance 2004 CanLII 22955 Ont S C
As part ofa previous settlement Crown Life paid the plaintiff 59 000 lump sum for her difficulties
during the times when her payments were held up para 9
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It is important however that steps be taken BEFORE the claim is drafted to
identify specific instances and occurrences that might support a claim for bad
faith and or aggravated damages Kennedy v Manulife29 is authority for the
proposition that a claim that contains allegations without any factual backing of
bad faith conduct runs the risk of being struck out The best course of action is
to do your homework before the claim is drafted plead specific allegations that
can be supported and refrain from making the bad faith argument in the absence
of compelling evidence
Conclusion
LTD litigation is likely to be an expanding area of the law in Ontario Claimants
are clearly disadvantaged by the fact that the LTD insurers write and interpret the
Policies However there are many weapons that an innovative advocate can
use to advance the rights of claimants that have wrongly been denied benefits
Thank you
292003 CanLII 32544 Ont S C
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