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Insured no longer entitled to long-term disability benefits because she can return to work: court

Saskatchewan court considered if insured who slipped on ice is covered according to policy

Insured no longer entitled to long-term disability benefits because she can return to work: court
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The Court of Queen’s Bench for Saskatchewan has upheld the defendant insurance company’s decision to terminate the personal injury plaintiff’s long-term disability benefits, finding that the plaintiff was capable of returning to non-physical and sedentary employment.

In Wondrasek v Fenchurch General Insurance Company, 2021 SKQB 30, the plaintiff, employed as a miner’s helper who had highly physical work duties, fell on some ice and suffered injuries including torn muscles in her left side, arm and neck. Following the accident in November 2011, which was not work-related, she stopped going to work beginning the next month. She was party to a group long-term disability insurance policy with defendant Fenchurch General Insurance Company.

The defendant paid the plaintiff short-term disability benefits for the maximum period, which ended in April 2012, then started paying the plaintiff long-term disability benefits during the “own” occupation period under the insurance policy, beginning April 2012, at $2,000 per month. This entitlement was extended periodically. In May 2013, the plaintiff underwent heart surgery for her heart condition and started using a pacemaker.

In February 2014, the defendant advised the plaintiff that it was suspending payment of the own occupation benefits because she had not provided updated medical reports as requested via a September 2013 letter. Even so, the defendant continued to pay benefits until May 2014. Upon the termination of the payment of the own occupation benefits, the defendant assessed that the plaintiff did not qualify for long-term disability benefits during the “any” occupation period under the insurance policy. The defendant rejected both of the plaintiff’s appeals of the termination of her long-term disability benefits.

The plaintiff filed a claim for long-term disability benefits with the Court of Queen’s Bench for Saskatchewan, stating that she disagreed with the defendant’s assessment that she did not meet the definition of disabled at the time her benefits converted from own occupation benefits to any occupation benefits. The defendant, on the other hand, sought summary judgment dismissing the plaintiff’s claim.

The Saskatchewan Court of Queen’s Bench granted summary judgment and dismissed the plaintiff’s claim. The court upheld the termination of the plaintiff’s benefits, noting that the defendant undertook a comprehensive review and took numerous steps to determine whether the plaintiff was entitled to benefits throughout this process, including through the conduct of the first and second appeals, a peer-to-peer review, a functional capacity evaluation and a transferable skills analysis. The defendant also offered the plaintiff numerous opportunities to submit her medical information.

The court considered the evidence and found that, while the plaintiff was not able to return to her own occupation, she was capable of returning to non-physical and sedentary employment and did not meet the definition of disabled under the any occupation benefits portion of the insurance policy. Among the evidence of medical experts and specialists, the court preferred the timely assessment which post-dated the plaintiff’s heart surgery and which stated that the plaintiff could now return to non-physical work.

On the issue of whether the plaintiff was medically able to perform any occupation, the court found that the defendant relied upon medical information and independent evaluations to support its determination that the plaintiff could return to non-physical employment and had properly established that there was no genuine issue requiring trial. The burden then shifted to the plaintiff, who failed to refute or counter this evidence, the court said.

On the issue of whether the plaintiff had the minimum qualifications for any occupation, the court also said that the defendant presented evidence which confirmed that the plaintiff had the minimum qualifications to perform other employment and sufficiently proved that there was no genuine issue requiring trial. The court said that the plaintiff again failed to refute or counter the defendant’s evidence on this matter.

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