Saskatchewan's top court has ruled an auto insurer's unappealed benefit decision is not necessarily final if a later decision letter revisits the same issue.
The Court of Appeal for Saskatchewan has dismissed an appeal by Saskatchewan Government Insurance (SGI) over income replacement benefits owed to a claimant injured in a 2005 hit-and-run collision, while allowing the claimant's own appeal for an additional benefit period.
The claimant was struck by a vehicle in Saskatoon on June 18, 2005, suffering a brain injury, a spinal fracture, and other serious injuries. He applied to SGI for income replacement benefits under Saskatchewan's no-fault automobile insurance scheme. Over the following two decades, as his employment situation and medical condition changed, SGI reviewed his file numerous times, issuing decision letters that instituted, terminated, or reinstated his benefits.
In a decision letter issued in May 2010, SGI determined the claimant was capable of an eight-hour workday at a medium physical level and ended his benefits effective May 2011. He did not appeal that letter within the statutory 90-day window.
After a dispute over a later recurrence of seizures, SGI accepted a relapse date of August 7, 2014, and issued a further decision letter dated August 25, 2020, assessing his benefit entitlement for the relapse period on the basis that he had been unemployed, rather than unable to work, when the relapse occurred. When the claimant appealed to the Court of King's Bench, the judge awarded him benefits for several disputed periods but ruled that his entitlement between May 2011 and August 2014 could not be revisited, since the 2010 letter had gone unappealed.
Justice Jeffery Kalmakoff, writing for the Court of Appeal, disagreed. He found the 2020 decision letter was itself premised on the validity of the earlier 2010 determination, meaning the claimant's appeal from the 2020 letter reopened that determination for review. Rejecting SGI's position that an unappealed decision becomes permanently unreviewable, Kalmakoff wrote that such an interpretation "cannot be what the Legislature intended."
The court also confirmed that appeals from SGI decision letters proceed as de novo hearings, so claimants are not limited to the evidence that was before the insurer when the original decision was made.
As a result, the Court of Appeal varied the lower court's decision to hold that the claimant is also entitled to income replacement benefits for the May 2011 to August 2014 period, on top of the benefits already awarded below. The court awarded the claimant costs of the appeals and leave applications.
