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Insurer Entitled to Repayment Beyond 12 Months Due to Wilful Misrepresentation of Post-Accident Employment Status

August 14, 2023

In the recent Licence Appeal Tribunal (LAT) decision, The Personal Insurance Company v Beason (21-006574/AABS), Adjudicator Norris found that The Personal was entitled to a repayment of income replacement benefits (IRBs), including interest, from Beason beyond 12 months as a result of wilful misrepresentation or fraud.

In this claim, Beason was involved in a motor vehicle accident on February 4, 2017. Beason submitted an Application for Accident Benefits dated February 27, 2017, Disability Certificates dated March 1 and August 29, 2017, and Employment Confirmation Forms dated April 12 and August 3, 2017.  In all these documents, Beason indicated that he was unable to work as a result of the accident.  Accordingly, The Personal commenced paying Beason IRBs. Beason continuously reported to insurer’s examination assessors and his own healthcare providers that he never engaged in any employment following the accident.

However, per Beason’s 2017 T4 Statement of Remuneration, he earned employment income from one of his two employers that is commensurate with full-time hours at the same hourly rate noted on his pre-accident pay statements.

Adjudicator Norris opines, “The T4 statement holds considerable weight because it is a government document filed by an employer and it is required to be accurate for tax collection purposes – there is no benefit to the employer for falsely reporting an employee’s income.

To-date, Beason has made no attempt to explain the discrepancy between his reports to The Personal and his tax documents.  In addition, Beason has failed to produce any post-accident pay statements or a return-to-work date.

Adjudicator Norris states, “I conclude from the evidence that Beason returned to full-time employment at one of his two employers following the accident. However, he continued to advise The Personal and his healthcare providers that he was unable to work. I conclude that the sole purpose of misrepresenting his employment status was for Beason to receive IRBs at a time when he is not entitled to the benefit.”

Section 52(1) of the Statutory Accident Benefits Schedule for accidents occurring on or after September 1, 2010 (SABS) indicates “a person is liable to repay to the insurer, (a) any benefit described in this Regulation that is paid to the person as a result of an error on the part of the insurer, the insured person or any other person, or as a result of wilful misrepresentation or fraud.

In Section 52(2), “If a person is liable to repay an amount to an insurer under this section, (a) the insurer shall give the person notice of the amount that is required to be repaid.

Finally, in Section 52(3), “If the notice required under subsection (2) is not given within 12 months after the payment of the amount that is to be repaid, the person to whom the notice would have been given ceases to be liable to repay the amount unless it was originally paid to the person as a result of wilful misrepresentation or fraud.”

Adjudicator Norris concludes that The Personal satisfied the notice requirements on March 19, 2020, and June 3, 2021, per Section 52 of the SABS: The Personal’s entitlement to a repayment is not limited to 12 months because Beason wilfully misrepresented his employment status while receiving IRBs.  Accordingly, Beason is required to repay all IRBs to The Personal of $60,984.73, plus interest.

Read the decision in full detail here: The Personal Insurance Company v Beason (21-006574/AABS)

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