Insurance Binder

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[LEGAL ISSUES OF INTEREST TO THE INSURANCE INDUSTRY]=
Winter 2010
Addressing Issues of Capacity
in Accident Benefits
Settlements
This quarterly newsletter offers the
insurance industry a defence counsel
perspective on claims management, from the
initial investigation through to trial, with
reference to relevant court decisions, statutes
and regulatory provisions.
In accident benefits cases, an area that can
frequently cause difficulties is resolving
claims where issues of capacity are
suspected. In such cases, the golden rule
should be: when in doubt, seek court
approval. To be of assistance, we suggest
that the following steps be taken to increase
the likelihood of negotiating a successful
settlement in these circumstances.
Given that our Insurance Defence Group
practises in both official languages
throughout both Ontario and Quebec, we
have included articles in both French and
English.
Your comments are appreciated, and if you
have any insurance defence, subrogation or
coverage issues that you would be interested
in reading about, please feel free to contact
any of our lawyers at the coordinates noted
on the last page of this newsletter.
(1) Request details concerning any
attorneys or guardians for the insured.
Ensure that you are negotiating with the
correct person. If the insured has already
been found to be incapable, then you want to
be dealing with the attorney or guardian. If
no such finding has been made, details
concerning existing attorneys or guardians
(either for property or personal care) may
assist with any court applications that may
be required later on.
Articles
Pg. 1 Addressing Issues of Capacity in
Accident Benefits Settlements
Pg. 4 Mandatory Mediation and Discovery
Procedures: The Changes
Pg. 7 Recours des victimes d’accidents
automobiles impliquant un véhicule
insuffisamment ou non assure.
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(4) Make the settlement conditional on a
capacity
assessment
and/or
court
approval.
(2) Take detailed notes.
Detailed notes should be taken of any
capacity concerns. Make particular note of
any of the following: confused or delusional
thinking; inability to make settled choices;
severe pain, fear, anxiety or depression;
impairment due to drugs or alcohol; and
observations about the insured’s behaviour
or communications. These can be indicia of
problems. If the insured is having difficulty
understanding questions or conversations,
make note of the subject matter that is
causing difficulty. If a full and final
settlement is being discussed, be sure to note
a specific breakdown of the benefits being
settled, and the amounts being paid for each
benefit. Also be sure to note which benefits
are past and which future to better deal with
interest, if necessary.
A capacity assessment under the Substitute
Decisions Act, 1992 can be obtained, but
only with the person’s consent or a court
order. Depending on your concerns, you
can request the insured to submit to a
capacity assessment in order to obtain court
approval of any settlement. You can also
explain that court approval is also in their
best interests, as it will ensure a fair
settlement. If the insured refuses, you can
bring a court application for the assessment,
and a subsequent application for court
approval.
(5) Agree to pay benefits and interest
pending approval, if appropriate.
You can expect delays in obtaining both a
capacity assessment and court approval.
Depending the delay, you can expect a judge
to be concerned about ongoing benefits and
interest. You will want to make sure that the
insured continues to receive necessary
services pending approval. Any settlement
agreement should specify that benefits
continue uninterrupted pending approval,
with amounts paid being deducted from the
appropriate portion of the settlement. This
way, the insured is protected against delays
and problems if approval is denied. Any
such agreement will need to be specified in
the Settlement Disclose Notice and the
release. For lump sums, the insurer keeps
the benefit of the funds pending approval,
which may pose a problem if the concerns
about capacity prove unwarranted. An
agreement to pay interest may be
appropriate.
(3) Advise the insured that you have
concerns, and suggest independent legal
advice.
Most settlement documentation includes a
clause whereby the insured acknowledges
that they have had the opportunity to seek
independent legal advice. If you suspect an
insured may lack capacity, you should
actively encourage them, in writing, to take
advantage of that opportunity. There is an
ethical obligation placed upon lawyers and
registered paralegals to obtain the assistance
of public guardians if necessary. Directing
the insured for independent legal advice may
start the necessary chain of events to address
the issue. Additionally, the threshold for
capacity to grant a power of attorney is
lower than the threshold for capacity itself,
so independent counsel may assist the
insured by appointing an attorney.
2
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Winter 2010
be found. The capacity assessment will
satisfy the first requirement, and the
inquiries into the existence of any
attorney(s) or guardian(s) will assist with the
second.
(6) Bring a court application for an order
compelling the capacity assessment.
Assuming that the insured does not consent
to a capacity assessment, you may want to
bring an application for a court order. The
application will determine whether there are
“reasonable grounds” to doubt capacity, and
the detailed notes taken of any concerns will
be
central
to
that
determination.
Additionally, an agreement to pay ongoing
benefits and/or interest pending the results
should ease any concerns that the insured
will be prejudiced by the procedure.
Once a litigation guardian is appointed, they
will be required to review the settlement,
and appoint counsel (if it is not the Public
Guardian and Trustee). Counsel and the
litigation guardian will then be required to
provide affidavits outlining their positions
concerning the settlement.
(8) Renegotiate the settlement, if need be.
If the court concludes that reasonable
grounds do not exist, that determination
should be sufficient to protect the insurer,
and the settlement can be finalized. If the
court concludes that reasonable grounds do
exist, the court should order a capacity
assessment. If the capacity assessment
concludes that the insured is capable, that
assessment should be sufficient to protect
the insurer, and the settlement can be
finalized.
If the capacity assessment
concludes that the insured is incapable, then
court approval will have to be obtained.
If counsel and/or the litigation guardian
support the settlement, it will go before the
court for approval. If counsel and/or the
litigation guardian do not support the
settlement, however, it will need to be
renegotiated in order to obtain court
approval. While renegotiating a settlement
agreement may not seem attractive it is
important to remember that the settlement
agreement is not binding without court
approval, and it will be practically
impossible to obtain court approval without
counsel and/or the litigation guardian
supporting the application. In the
circumstances renegotiation, while certainly
not ideal, is presumably better than no
settlement, or else the claim would simply
be kept open.
(7) Apply for court approval, and request
that a litigation guardian be appointed.
Assuming a lack of capacity, a further
application will have to be brought for court
approval. The Rules of Civil Procedure
require that affidavits be filed on behalf of
the lawyer and litigation guardian of the
person under a disability explaining why the
settlement is appropriate. The Rules of Civil
Procedure specifically state that the Public
Guardian and Trustee can be appointed
where a party has been found incapable
under the Substitute Decisions Act, 1992,
and no other suitable litigation guardian can
James Brown
Lawyer, Insurance Defence Group
613-231-8345
[email protected]
3
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Mandatory Mediation and
Discovery Procedures: The
Changes
Winter 2010
Honour concluded that such discovery
problems arose less frequently in small
communities where collegiality and
cooperation among members of the bar
tended to limit abuses of the discovery
process.
In November 2007, The Honourable Justice
Coulter Osborne delivered recommendations
to Ontario’s Attorney General on reforming
Ontario’s Civil Justice system to make it
more affordable and accessible to litigants
and potential litigants. Justice Osborne’s
recommendations
included
extensive
changes to the Rules of Civil Procedure.
Those changes came into effect on January
1, 2010 and represent the more extensive
changes to the Rules of Civil Procedure in a
quarter century.
In a general sense, Justice Osborne
recommended that overall discovery reform
was required in order to deal with those
lawyers who made excessive requests or
otherwise abused the discovery process. To
address those abuses, a number of key
changes to the discovery process came into
effect January 1, 2010. Broadly, those
changes are:
(i)
In our last issue of Insurance Binder, we
reviewed the changes to the Rules with
respect to the increase in the monetary
jurisdiction of the Small Claims Court and
of the Simplifed Procedure. In this issue, we
examine how the Rule changes affect
discovery and mandatory mediation.
(ii)
Prior to January 2010, the Rules of Civil
Procedure provided a relatively broad scope
of documents that were required to be
produced by way of documentary discovery.
The “old Rules” were equally broad with
respect to the scope of questions that were
permitted on examination for discovery.
Generally speaking, the “old Rules”
provided that every document "relating to
any matter in issue" was to be disclosed in
an affidavit of documents and any question
that has a "semblance of relevancy" to the
matters in the issue in the litigation could be
asked on examination for discovery.
(ii)
the scope of documents to be disclosed
in an affidavit of documents has been
be narrowed, from those “relating to
any matter in issue" to those "relevant
to any matter in issue";
the scope of questions that can be
asked on examination for discovery
has been narrowed, from those
"relating to any matter in the issue" to
those "relevant to any matter in issue";
the introduction of time limits to
examination for discovery, prohibiting
a party from conducting any
examination for discovery of longer
than 7 hours in duration, except on
consent or with leave of the court;
(iii) the introduction of the requirement for
filing written “discovery plans”; and
(iv) the introduction of the concept of
“proportionality” in the discovery
process.
In reviewing the “old Rules” with respect to
discovery, Justice Osborne found that
discovery problems exist in some areas of
the province, principally in Toronto. His
The narrowing of the scope of documentary
production and questions that can be asked
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information intended to result in the
expeditious and cost effective completion of
the discovery process proportionate to the
importance and complexity of the action.
on examination for discovery will likely
have relatively minimal implications for
insurers in most cases; the practical reality is
that these Rule changes are not targeted to
lawyers who make reasonable discovery
requests, but rather those who abuse the
rules as they were structured. Having said
that however, the change in the Rule with
respect to the duration of examination for
discovery may have some impact on
insurers, particularly in those cases where
examination for discovery of all opposing
parties will reasonably require more than 7
hours and where the opposing parties will
not consent to examination longer than that
7 hour duration.
The fact that the discovery plan must be
agreed to relatively early in the litigation
process necessarily means that counsel and
insurers must be mindful not to commit to
an overly ambitious or unduly narrow
discovery plan that could potentially restrict
one's ability to obtain complete documentary
and oral evidence in the discovery process
as the action moves forward. By way of
example, at the time a discovery plan is
entered into, an insurer and counsel may not
have a complete picture of the scope of
documents that may be in an insured’s
possession or may not even be in a position
to ascertain who will be produced for
examination for discovery on behalf of the
insured.
In such instances, which are
relatively common, one must take care to
ensure that the discovery plan committed to
early in the process guards the interests of
the insured and the insurer moving forward
through the litigation. The best way to
ensure that a discovery plan entered into at
the outset of the litigation takes into account
these concerns is to ensure early and open
communication among all of the insured, the
insurer and counsel.
In considering whether to grant leave to
allow more than 7 hours of examination for
discovery, the court will look at a number of
factors including the amount of money in
issue, the complexity of the issues of fact or
law, the amount of time that ought
reasonably be required for oral examination,
the financial position of each party, the
conduct of any party and a party's denial or
refusal to admit anything that should have
been admitted.
In addition to the time limitations with
respect to conducting oral examination for
discovery, the new Rules also provide that
all parties to an action must agree to a
discovery plan. Generally, that plan must be
agreed to within 60 days after the close of
pleadings. The plan must be in writing and
must include the intended scope of
documentary discovery, the dates for the
service of each party's affidavit of
documents, information respecting the
timing, costs and manner of the production
of documents, the names of persons
intended to be produced for oral
examination for discovery and any other
Finally, it is important to note that where the
parties to an action fail to agree to a
discovery plan, the Court may refuse to
grant any relief or to award costs on any
subsequent discovery type motions [i.e.
compelling the opposing party to produce a
proper affidavit of documents, compelling
the opposing party to answer a question on
examination for discovery, challenging a
claim of privilege, etc.]
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Winter 2010
particularly significant impact upon insurers,
claims examiners, adjusters and their
counsel. The reality is that insurers have
grown accustomed to mediation through the
patchwork of mediation regimes already in
place in the industry [i.e. pursuant to the
Insurance Act, the Statutory Accident
Benefits Schedule and case management
mediation], and the new regime seems to be
simply another step in the evolution of
moving toward alternative dispute resolution
processes which may be somewhat more
"user friendly" than the old mandatory
mediation rule [particularly in terms of the
timing of the mediation session].
Beyond changes to the discovery process,
the Rules with respect to court mandated
mediation have also been significantly
revamped. While mandatory mediation has
been a fixture of case managed actions
commenced in Ottawa and Toronto over the
past 10 years and has remained a component
of all actions commenced in Ottawa since
that time, there has effectively been a
"patchwork" of rules and practice directions
in the City of Toronto that resulted in a
number of cases not being subject to
mandatory mediation.
Effective January 1, 2010, all civil actions
commenced in Ottawa, Toronto and
Windsor, whether case managed or not, are,
for the most part, subject to mandatory
mediation.
Although this article has only addressed
some of the principle changes of the Rules
of Civil Procedure with respect to discovery
and mediation, it appears clear that the
totality of the Rule changes will have a
profound and evolving
effect on the
handling of claims for insurers, claims
examiners, legal counsel and other players
in the civil justice system.
Stay tuned for our follow-up reports and
articles on the Court's interpretation of the
Rules and how those interpretations impact
on all participants in the litigation system.
As far as insurers are concerned, the key
exception to the mandatory mediation rule is
in respect of actions that were the subject of
mediation pursuant to section 258.6 of the
Insurance Act, provided that such mediation
was conducted less than one year before the
delivery of a first defense in the action.
The other key changes to the mandatory
mediation rules are with respect to the
timing of the mediation session. Under the
“old Rules”, mediation was required to be
held within 90 days after a first defence was
filed and could be postponed for up to 60
days or beyond that period, if the consent of
the parties was filed with the Court. Under
the “new Rules”, mediation is only required
to take place within 180 days of a first
defence being filed and the mediation
session may be postponed with the written
consent of all parties.
Colin Dubeau
Lawyer, Insurance Defence Group
613-231-8367
[email protected]
From a practical perspective, the changes to
the mediation rules will not have a
6
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Recours des victimes
d’accidents automobiles
impliquant un véhicule
insuffisamment ou non assuré :
lorsqu’un même accident
génère plusieurs délais de
prescription.
dommages subis dans ledit accident. Ce
droit
d’action
réglementaire
vient
évidemment s’ajouter à celui existant en
Common Law contre la personne fautive. La
réalité pratique est que la personne fautive
qui conduit un véhicule non suffisamment
assuré est rarement en mesure de faire face à
une condamnation à des dommages-intérêts
importants, si bien que souvent, le seul
recours viable de la victime est celui contre
son propre assureur.
Contexte
En droit des assurances, comme en bien
d’autres matières, le délai de prescription
d’un droit d’action, qui délimite le risque qui
incombe autrement au défendeur, est un
facteur essentiel de certitude juridique. Il est
en conséquence important que le délai de
prescription applicable à un cas particulier
d’espèce soit déterminé ou déterminable
aisément par les défendeurs, puisque
l’application d’un délai de prescription peut
venir dicter leur comportement.
Les différents droits d’action
L’affaire de ce recours réglementaire aurait
pu être simple, elle ne l’est pas : car en
réalité, ce n’est pas un droit d’action, mais
plusieurs droits d’actions distincts qui ont
été reconnus par la Cour d’Appel de
l’Ontario, dans des affaires déjà anciennes.
Visiblement, ces décisions de la Cour
d’Appel n’ont pas retenu l’attention des
praticiens, si l’on en croit les « rappels »
successifs jugés nécessaires par la Cour
d’Appel.
En Ontario, dans l’immense majorité des
cas, le délai de prescription est
effectivement facilement déterminé, à savoir
deux années à compter de la possibilité de
découverte d’un droit d’action. Il existe
cependant en matière de prescription un
particularisme relatif aux demandes faites
par les personnes victimes d’accidents
automobiles dans lesquels les véhicules
fautifs ne sont pas suffisamment ou pas du
tout assurés.
Le résultat de ces décisions de la Cour
d’Appel
interprétant
le
règlement
« Uninsured Automobile Coverage » est que
le point de départ du délai de prescription de
deux ans varie selon la méthode
d’indemnisation choisie par la victime
contre son assureur pour les dommages
subis par la faute d’un véhicule non
suffisamment ou pas assuré.
Dans ces cas où la personne fautive conduit
ou est propriétaire d’un véhicule qui n’est
pas assuré de façon à pouvoir couvrir la
totalité des dommages de la victime, cette
dernière dispose aux termes du règlement
« Uninsured Automobile Coverage », pris en
application de la Loi sur les Assurances1,
d’un droit d’action à l’encontre de son
propre assureur automobile pour les
1
Winter 2010
Dans Johnson v. Wunderlich2, la Cour
d’Appel a en effet identifié trois méthodes
d’indemnisation à la disposition des
victimes dans ces circonstances :
•
2
R.R.O. 1990, Reg. 676
La personne blessée peut intenter une
action contre le fautif/responsable seul,
[1986] O.J. No. 1251, 57 O.R. (2d) 600 (C.A.)
7
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•
•
et après avoir obtenu une décision de
justice en sa faveur, peut demander le
paiement des sommes accordées par la
cour à son assureur.
La personne blessée peut intenter une
action contre son assureur seul.
La personne blessée peut intenter une
action contre son assureur et contre la
personne fautive.
Winter 2010
aux deux autres méthodes d’indemnisation à
la disposition de la victime énoncée par la
Cour d’Appel dans Johnson v. Wunderlich.
•
Dans le cas d’une action contre
l’assureur seul, à savoir une demande
en indemnité des dommages causés par
la personne fautive qui sont en excès
de
la
couverture
d’assurance
disponible aux termes de la police
d’assurance du véhicule fautif, le droit
d’action court à compter du jour où la
victime a connaissance (i) des
blessures justifiant une action et (ii) de
l’insuffisance de ladite couverture
d’assurance du véhicule fautif.
•
Dans le cas d’une action contre la
personne fautive uniquement, la
prescription court du jour où la victime
a connaissance de blessures justifiant
une action, à savoir des blessures
permanentes et sérieuses passant le
seuil légal créé par la Loi sur
l’assurance.6
Selon la méthode d’indemnisation retenue,
le délai de prescription de deux ans
commence à courir ainsi:
•
La Cour d’Appel spécifia dans Foster
v. Young3, une décision rendue en
2002, que, lorsque la victime intente
une action contre son assureur après
avoir obtenu un jugement contre la
personne fautive, le droit d’action ne
naît qu’au moment du refus par
l’assureur de payer ledit jugement. La
même juridiction, dans Caruso v.
Guarantee Co. of North America4,
précisa que le refus de l’assureur,
avant qu’une action contre l’assureur
ne soit engagée, ne fait pas courir le
délai de prescription. C’est également
à cette conclusion qu’est parvenu
Justice Pepall dans Din v. Hage5, une
décision rendue par la Cour Supérieure
de Justice en 2006 et confirmée par la
Cour d’Appel en 2007.
Conséquences pour l’assureur de la
victime
La
situation
juridique
créée
par
l’interprétation du Règlement « Uninsured
Automobile Coverage » faite par la Cour
d’Appel est en apparence incongrue en ce
que deux droits d’action différents à
l’encontre de l’assureur de la victime
peuvent voir le jour à partir d’un même et
unique accident. Cela peut conduire à une
situation dans laquelle le recours direct en
indemnité à l’encontre de l’assureur peut
être prescrit, par exemple dans le cas où la
victime n’a pas intenté de demande en
Ce délai de prescription de deux ans à
compter du refus de l’assureur de la victime
de payer le montant des dommages obtenus
après jugement est à contraster avec les
délais, plus traditionnels, qui s’appliquent
3
[2002] O.J. No. 3774 (C.A.)
[1996] O.J. No. 4072, 31 O.R. (3d) 339 (C.A.)
5
[2006] O.J. No. 2805 (S.C.J.); [2007] O.J. No. 3636
(C.A.)
6
Insurance Act, R.S.O. 1990, CHAPTER
I.8, s. 267.5
4
8
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Winter 2010
responsabilité de la personne soi-disant
fautive si le jugement résulte d’une demande
qui n’a pas été contestée.
Ces deux
conditions permettent à l’assureur un
opportunité
d’établir
des
réserves
appropriées, et évitent à l’assureur de devoir
payer un jugement résultant d’une action qui
aurait pu être défendue et qui ne l’a pas été.
Enfin, le jugement doit avoir été rendu par
une cour de l’Ontario, et non dans une autre
juridiction.
indemnité contre son propre assureur dans
les deux ans après avoir eu connaissance du
défaut ou de l’insuffisance d’assurance du
véhicule fautif, sans que le droit d’action en
paiement du jugement obtenu contre la
personne fautive ne soit prescrit, bien qu’il
s’agisse du même accident.
Cela veut dire qu’un assureur qui se croit
hors d’affaire, peut se voir « rattraper »
après que la victime a obtenu un jugement
contre la personne fautive, et cela bien des
années après l’accident. Bien que ce résultat
génère en apparence
une certaine
incertitude juridique, il est cependant justifié
par des raisons d’intérêt public et il contient
des mesures de sauvegarde des intérêts
légitimes des assureurs.
Recommandations pratiques
Il n’en reste pas moins que l’assureur qui se
voit mis en cause pour la première fois après
jugement risque de se retrouver les mains
liées dans la mesure où il devra défendre une
action parfois plusieurs années après
l’accident, et dans laquelle la personne
responsable n’est pas une partie. Afin
d’éviter cette situation, il est recommandé à
l’assureur de la victime de faire une enquête
des faits appropriée dès que son assuré lui
rapporte l’accident. De même, il peut être
utile à l’assureur d’intervenir à l’instance
afin de faire valoir les éléments de défense
que la personne fautive ne saura ou ne
voudra pas mettre en avant lui-même du fait
de ses ressources financières limitées. Cela
permet en effet à l’assureur de prendre les
commandes de l’action en justice contre la
personne fautive et de clore son dossier plus
rapidement, plutôt que de s’exposer à des
dommages
supérieurs
à
une
date
potentiellement très éloignée de l’accident.
Les raisons de la protection de l’intérêt
public nous sont indiquées par Justice
Finlayson dans Caruso : une approche rigide
de la prescription dicterait que dans chaque
affaire,
le
demandeur
joindrait
immédiatement à la cause son propre
assureur, sans même avoir connaissance
certaine de l’insuffisance de la couverture
d’assurance du véhicule fautif, uniquement
pour s’assurer de ne pas se voir opposer un
délai de prescription potentiellement
difficile à cerner.
Quant aux mesures de sauvegarde des
intérêts légitimes de l’assureur de la victime,
elles sont doubles : d’une part, l’obligation
de paiement des dommages de la victime par
l’assureur est conditionnelle à l’obligation
des assurés de se plier aux règles imposées
par le règlement « Uninsured Automobile
Coverage », et notamment celle de reporter
sans délai les faits donnant lieu au jugement
contre la personne fautive. D’autre part,
l’assureur peut disputer pour la première fois
le montant des dommages et la
Fabrice Gouriou
613-231-8310
[email protected]
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Nelligan O'Brien Payne – Insurance Binder Newsletter
Winter 2010
Our Insurance Defence Practice Group
Lawyers
Susan Bromley
James Brown
Peter Cronyn
Stacey Cronyn
Colin Dubeau
Practice Group Leader
Jessica Fullerton
Fabrice Gouriou
Joseph Griffiths
Patricia Lawson
John Lundrigan
Raymond Murray
Al O’Brien
Craig O’Brien
Mark Seebaran
Tom Yen
613-231-8355
613-231-8345
613-231-8213
613-231-8272
613-231-8367
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
613-231-8366
613-231-8310
613-231-8369
613-231-8290
613-231-8325
613-231-8305
613-231-8224
613-231-8331
613-231-8352
613-231-8281
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
Insurance Binder is not intended to provide
legal advice or opinion as neither can be given
without reference to specific events and
situations.
Questions and comments concerning materials in
this newsletter are welcomed. Please feel free to
contact the author of the article.
Copies of this newsletter are also posted on our
Web site at www.nelligan.ca.
© Copyright 2010 Nelligan O’Brien Payne LLP
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