Table of Contents Division 11 11.0 Insurer s Decisions and Appeals 11.1 Summary Information 11.1.1 Division 11 Legislation Section 188 - Insurer s decisions final Section 189 - Insurer to give written reasons Section 190 - Mediation Section 191 - Right to appeal Section 192 - Court rules apply to proceeding before the court Section 193 - Conduct of appeal before appeal commission Section 194 - Appeal to the Court of Appeal Section 195 - Variation of compensation Section 195.1 - Dismissal of appeal for want of prosecution of appeal Section 196 - Appeal does not stay decision 11.1.2 Part X Regulations Section 84 - Fee for mediation Section 85 - Appointment of mediator Section 86 - Applications for appeal Section 87 - If claimant is incapable Section 88 - Notice of appeal and hearing Section 89 - Records and information Section 91 - Hearing by appeal commission Section 92 - Hearings public Section 93 - Adjournments Section 94 - Subpoena Section 95 - Appeal commission to compile record of hearing Section 96 - Reimbursement of expenses Section 97 - Failure to attend Section 98 - Discontinuance of appeal Section 99 - Queen s Bench location of proceeding Section 100 - Application to vary 11.2 Division 11 Policies, Procedures, and Information 11.2.1 Decision Letter Requirements SGI s decisions final SGI to provide written reasons When SGI must provide a written decision letter Prior to issuing a written decision When SGI provides a decision 101 days to request appeal or mediation Contact with the customer Manner of service If a decision letter is returned Reconsideration of SGI s decision Division 11 Table of Contents 1
11.2.2 The Appeal Process Overview of the appeal process Information required on an Appeal Summary Proceeding with appeal Injury claim handling during appeal Decision provided by the appeal commission PJI if appeal is overturned Reimbursement of appeal fee Submission of the Application for Appeal 11.2.3 Mediation Overview of the mediation process Request for mediation Selection of a mediator Subsequent requests for mediation Who is to attend mediation Mediation accounts Mediator to close mediation in writing Division 11 Table of Contents 2
11.1.1 Division 11 Legislation (11.1.1-01/2017) Effective January 1, 2017 Purpose Provides a detailed overview of the Act with respect to SGI s decisions and appeals. Act 188 189 190 191 192 193 194 195 195.1 196 Insurer s decisions final Insurer to give written reasons Mediation Right to appeal Court rules apply to proceeding before the court Conduct of appeal before appeal commission Appeal to the Court of Appeal Variation of compensation Dismissal of appeal for want of prosecution of appeal Appeal does not stay decision Section 188 Insurer s decisions final (Act, s 188): Any decision made or action taken by SGI pursuant to this Part is final and conclusive and may be reviewed only in accordance with this Division. Section 189 Insurer to give written reasons (Act, s 189): SGI shall give every customer a written decision respecting the customer s entitlement to benefits. At the time SGI sends a customer a written decision, it shall give the customer: written reasons for the decision written notice of the customer s right to ask for mediation or to appeal SGI s decision pursuant to this Division Section 190 Mediation (Act, s 190): If a customer wishes to mediate his or her claim for benefits, the customer shall provide SGI with a written notice requesting mediation. A customer shall: provide the written notice mentioned above to SGI within 90 days after the date the customer received SGI s written decision pursuant to section 189 set out in the written notice the matters that the customer wishes to mediate pay any prescribed fee Note: SGI s policy is to provide the customer with the option to provide written notice requesting appeal or mediation within 101 days from the date of SGI s decision letter to allow adequate time for delivery of the decision letter. 11.1.1 Division 11 Legislation 1
Mediation is to be conducted in the prescribed manner. The parties shall agree on the appointment of a mediator within 30 days after SGI receives a written request for mediation. If the parties are unable to agree on a mediator within 30 days, a mediator must be appointed in the prescribed manner. A mediator appointed pursuant to this section shall endeavour to assist the parties to resolve the issues that are the subject of the mediation. Except with the written consent of the mediator and all parties to an action who participated in the mediation, the following are not admissible as evidence in any appeal: evidence arising from anything said in the course of the mediation anything said in the course of the mediation any oral or written admission or communication made in the course of the mediation When the mediator determines that the mediation is completed, the mediator shall provide each party with a written statement declaring that the mediation is completed. Section 191 Right to appeal (Act, s 191): A customer may appeal a decision of SGI to either the Court of Queen s Bench or the appeal commission within the later of: 90 days after the date of SGI s written decision; and If a customer has requested mediation pursuant to section 190, 90 days after the date of the mediator s written statement declaring that the mediation is completed. Note: SGI s policy is to provide the customer with the option to provide written notice requesting appeal or mediation within 101 days from the date of SGI s decision letter to allow adequate time for delivery of the decision letter. If a customer appeals a decision of SGI to: The Court of Queen s Bench - no proceeding respecting the matter may be taken before the appeal commission; or The appeal commission - no action or proceeding respecting the matter may be taken before the Court of Queen s Bench. Section 192 Court rules apply to proceeding before the court (Act, s 192): An appeal to the Court of Queen s Bench is to be conducted in accordance with The Queen s Bench Rules respecting actions commenced by statement of claim. If SGI is obligated to pay a customer s bill of fees and disbursements in an appeal, SGI is deemed to be a person charged with the bill and may apply for taxation of the customer s bill of fees to a taxing officer in the same manner as costs pursuant to The Queen s Bench Rules or The Legal Profession Act, 1990. 11.1.1 Division 11 Legislation 2
Section 193 Conduct of appeal before appeal commission (Act, s 193): This section applies to appeals before the appeal commission. A customer may commence an appeal to the appeal commission in the prescribed manner. Subject to The Fee Waiver Act, a customer who commences an appeal to the appeal commission must pay the prescribed fee of $75 (2016). An appeal to the appeal commission is to be conducted in the prescribed manner. Unless the customer puts them in issue, SGI s finding of facts must be adopted on appeal. If the customer puts SGI s finding of facts in issue, the appeal commission may hold a hearing to determine the facts. On an appeal, the appeal commission may: Set aside, confirm or vary SGI s decision; or Make any decision that SGI is authorized to make regarding No Fault benefits. The appeal commission shall provide the customer and SGI with written reasons for its decision. If the appeal commission determines that SGI should have paid the customer benefits other than those which SGI has been paying, the appeal commission may award interest on the value of the benefits not paid from the date when those benefits should have been paid until the date of the appeal commission s decision at the rate prescribed in section 210. A decision of the appeal commission is binding on SGI and the customer and may not be appealed except in accordance with this Division. Subject to the regulations, SGI shall reimburse a customer who is successful on appeal pursuant to this section or section 194 for the customer s costs in the prescribed amount. If SGI is obligated to pay a customer s bill of fees and disbursements in an appeal pursuant to this section, SGI is deemed to be a person charged with the bill and may apply for taxation of the customer s bill of fees to a taxing officer in the same manner as costs pursuant to The Queen s Bench Rules or The Legal Profession Act, 1990. Section 194 Appeal to the Court of Appeal (Act, s 194): SGI or the customer may appeal a decision of the Court of Queen s Bench or appeal commission to the Court of Appeal on a question of law only. An appeal pursuant to this section must be made within 30 days after the date of the decision of the Court of Queen s Bench or appeal commission or within any further time that a judge of the Court of Appeal may allow. Note: Decisions with respect to whether SGI will appeal a matter to the Court of Appeal are made by the SGI legal department. 11.1.1 Division 11 Legislation 3
Section 195 Variation of compensation (Act, s 195): A decision of the Court of Queen s Bench or the appeal commission made pursuant to section 191 or 193 may, at any time, be varied on the application of either the customer or SGI. A party who wishes to have a decision varied shall apply for leave to make an application for a variation to the Court of Queen s Bench or the appeal commission: By serving on the other party a copy of the application in the prescribed form; and By filing the application together with proof of service, with the Court of Queen s Bench or the appeal commission, whichever originally decided the matter. If the Court of Queen s Bench or the appeal commission is of the opinion that the customer has established a prima facie case that there has been a material change in the customer s circumstances, the Court of Queen s Bench or the appeal commission may grant leave to make an application for a variation. The provisions of section 192 or 193, as the case may be, apply, with any necessary modification, to an application for a variation pursuant to this section. Section 195.1 Dismissal of appeal for want of prosecution of appeal (Act, s 195.1): If an appeal before the appeal commission is not set down for hearing within six months after the application for appeal has been filed, the appeal commission may dismiss the appeal as abandoned. Before dismissing an appeal, the appeal commission shall notify the parties in writing that the appeal shall be dismissed unless the parties within 15 days after the date the notice is served on the parties apply to the appeal commission to show cause why the appeal should not be dismissed. If an appeal has been dismissed by the appeal commission, any money paid by the customer to initiate the appeal shall be refunded. Section 196 Appeal does not stay decision (Act, s 196): An appeal pursuant to this Division respecting a benefit does not stay or affect the validity of SGI s decision respecting the payment of a benefit. 11.1.1 Division 11 Legislation 4
11.1.2 Part X Regulations (11.1.2-01/2017) Effective January 1, 2017 Purpose Provides a detailed overview of the regulations with respect to SGI s decisions and appeals. Regulations 84 85 86 87 88 89 91 92 93 94 95 96 97 98 99 100 Fee for mediation Appointment of mediator Applications for appeal If claimant is incapable Notice of appeal and hearing Records and information Hearing by appeal commission Hearings public Adjournments Subpoena Appeal commission to compile record of hearing Reimbursement for expenses Failure to attend Discontinuance of appeal Queen s bench location of proceeding Application to vary Section 84 Fee for mediation (Regulations, s 84): A customer who requests mediation shall pay SGI a fee of $54 (2016). The customer shall pay the fee at the time the customer submits the customer s written notice requesting mediation pursuant to section 190 of the Act. Section 85 Appointment of mediator (Regulations, s 85): manager of mediation services means the manager of mediation services appointed pursuant to section 14.1 of The Department of Justice Act. If the parties are unable to agree on a mediator within the period mentioned in subsection 190(4) of the Act, either party may apply in writing to the manager of mediation services to appoint a mediator. On receipt of a written request to appoint a mediator and after consulting with both parties in any manner that the manager of mediation services considers advisable, the manager of mediation services shall appoint a mediator whom the manager of mediation services considers to be appropriate. An appointment of a mediator must be made within 30 days after the date on which the manager of mediation services received the written application. 11.1.2 Part X Regulations 1
Section 86 Applications for appeal (Regulations, s 86): An application to the appeal commission pursuant to section 193 of the Act: Must be made on a form provided by the appeal commission; and Subject to section 87, must be signed by the customer making the appeal. The prescribed fee for the purposes of subsection 193(3) of the Act is $75 (2016). If the appeal commission considers that payment of the prescribed fee will cause a substantial hardship for an appellant, the appeal commission may waive the fee. If the customer is successful on appeal, the appeal commission shall refund the prescribed fee to the customer. Section 87 If claimant is incapable (Regulations, s 87): An application to the appeal commission on behalf of that customer may be submitted and signed by a person authorized to represent the customer. A person who applies on behalf of another shall state in what capacity he or she is acting and provide proof of his or her capacity to act. Section 88 Notice of appeal and hearing (Regulations, s 88): business day means a day other than a Saturday, Sunday or holiday. On receipt of an application for appeal, the appeal commission shall serve a copy of the application for appeal on SGI within seven business days after receiving the application for appeal. The appeal commission shall give written notice of the time, date and place of the hearing to the customer and SGI of: at least 30 days; or any other period that the appeal commission considers reasonable in the circumstances. Section 89 Records and information (Regulations, s 89): As soon as is reasonably practicable after a customer submits an application for appeal to the appeal commission pursuant to subsection 86(1), the customer shall also submit: copies of all medical or financial documents supporting the application for appeal a list of the documentary evidence to be used at the hearing a list of the witnesses to be called at the hearing any other information that the appeal commission may require the relief sought from the appeal commission 11.1.2 Part X Regulations 2
As soon as is reasonably practicable after receiving a copy of an application for appeal pursuant to subsection 88(2), SGI shall forward to the appeal commission any record or other information in the possession of SGI that is relevant to the issues raised by a customer with respect to an appeal filed with the appeal commission. The appeal commission shall: Disclose all information, records and material filed with respect to the appeal by either the customer or SGI to the opposing party; Disclose to the parties, in advance of the appeal hearing, the name and title of any witness that the appeal commission is aware may be appearing before it at the appeal hearing; Give the customer and SGI a reasonable opportunity to examine all information, records and material filed with respect to the appeal before setting a date for an appeal hearing; and Provide the customer and SGI with copies of all material filed with respect to the appeal. Section 91 Hearing by appeal commission (Regulations, s 91): At a hearing by the appeal commission, there is to be full right: to examine, cross-examine and re-examine all witnesses; and to present evidence in defence and reply and to make submissions respecting the evidence before the commission. Section 92 Hearings public (Regulations, s 92): Unless the appeal commission orders otherwise, a hearing is open to the public. Section 93 Adjournments (Regulations, s 93): The appeal commission may, from time to time, adjourn a hearing. Section 94 Subpoena (Regulations, s 94): On application by the customer or SGI and on payment of the appropriate fee, the local registrar of the court at any judicial centre shall issue a writ of subpoena ad testificandum or subpoena duces tecum to the party requesting the subpoena. A subpoena issued must be served on the party to whom the subpoena is issued at least 10 days before the date scheduled for the appeal commission hearing. 11.1.2 Part X Regulations 3
Section 95 Appeal commission to compile record of hearing (Regulations, s 95): The appeal commission shall compile a record of a hearing that was held. The record of a hearing is to consist of: the written decision of SGI that was appealed; the notice of appeal to the appeal commission; any written submissions or affidavit evidence received by the appeal commission for the purposes of the hearing; the written decision of the appeal commission; any expert reports and opinions submitted to the appeal commission; and any evidence before the commission that was recorded in writing or by any electronic means. Section 96 Reimbursement for expenses (Regulations, s 96): For the purposes of subsection 193(11) of the Act, SGI shall reimburse a customer up to a maximum amount of $3,316 for all reasonable expenses incurred from the date of filing the appeal to the date of the judgment or the appeal commission s decision. reasonable expenses includes meals, lodging, travel expenses and expert reports. Section 97 Failure to attend (Regulations, s 97): If written notice of the time, date and place of the hearing has been given to the customer and the customer fails to attend the hearing, the appeal commission may: Hear and decide the appeal in the absence of the customer; Dismiss the appeal without conducting the hearing; or Grant an adjournment and assign a new time, date and place for the hearing. If the appeal commission assigns a new time, date and place for the hearing, the appeal commission shall give the customer and SGI written notice of that time, date and place. Section 98 Discontinuance of appeal (Regulations, s 98): A customer may abandon or discontinue all or any part of an appeal to the appeal commission at any time. If a customer abandons or discontinues an appeal or part of an appeal, the appeal commission, on the application of SGI, may award SGI its costs respecting the appeal in any amount that the appeal commission determines is appropriate. 11.1.2 Part X Regulations 4
Section 99 Queen s Bench location of proceeding (Regulations, s 99): A customer who appeals to the Court of Queen s Bench shall file his or her appeal at the judicial centre nearest to the place where the customer resides unless the customer and insurer agree otherwise. Section 100 Application to vary (Regulations, s 100): An application for leave to make an application for a variation of a decision of the Court of Queen s Bench or the appeal commission pursuant to section 195 of the Act must be made: In the case of an application for leave to make an application for a variation made to the Court of Queen s Bench, by notice of application in accordance with The Queen s Bench Rules. In the case of an application for leave to make an application for a variation made to the appeal commission, by completing an application form provided by the commission. If the Court of Queen s Bench or the appeal commission grants leave to make an application for a variation, the application for a variation must be made: In the case of an application for a variation made to the Court of Queen s Bench, by notice of application in accordance with The Queen s Bench Rules. In the case of an application for a variation made to the appeal commission, by filing an application setting out the following: the customer s name and address the file number, if applicable, assigned by SGI when the application for compensation was made; the relief sought the grounds to be argued, including a reference to any statutory provisions relied on; a copy of any affidavit evidence intended to be used copies of all medical or financial documentation, as the case may be, supporting the application for appeal any other information that the appeal commission requires Sections 86 to 98 apply, with any necessary modification, to an application to vary brought before the appeal commission. 11.1.2 Part X Regulations 5
11.2.1 Decision Letter Requirements (11.2.1-01/2017) Effective January 1, 2017 Purpose Provides a detailed overview of the Act, the regulations, and SGI s policies and procedures with respect decision letters issued to customers. Act 188 189 190 191 Insurer s decisions final Insurer to give written reasons Mediation Right to appeal Regulations 103 Manner of service SGI s decisions final SGI s decisions final (Act, s 188): Any decision made or action taken by SGI pursuant to this Part is final and conclusive and may be reviewed only in accordance with this Division. This means that if SGI has issued a decision letter regarding a customer s benefit entitlement under the No Fault program, the customer s only avenue to have the decision reviewed is via mediation and/or appeal. SGI to provide written reasons SGI to provide written reasons (Act, s 189): SGI shall give every customer a written decision respecting the customer s entitlement to benefits. At the time SGI sends a customer a written decision, it shall give the customer: written reasons for the decision; and written notice of the customer s right to ask for mediation or to appeal SGI s decision pursuant to this Division. Note: The timeframe in which the customer will be able to request mediation or appeal will also be outlined. When SGI must provide a written decision letter When SGI must provide a written decision letter: SGI must provide a written decision letter respecting the customer s entitlement to benefits including, but not limited to the following circumstances, where SGI: pays a benefit for the first time calculates or determines the amount of a benefit declines to provide a benefit requested by the customer declines to fund rehabilitation or treatment requested by the customer increases or decreases the amount of a benefit; does not provide full reimbursement of expenses submitted changes a prior decision made on file suspends a benefit concludes or terminates a benefit 11.2.1 Decision Letter Requirements 1
Note: Any time there is a change to the amount of a benefit or the manner in which the benefit is being adjudicated, if the decision impacts the customer s entitlement to a benefit, SGI must provide a written decision letter. A written decision must include the reasons for the decision as well as the facts that form the basis for the decision. Prior to issuing a written decision Prior to issuing a written decision: Prior to SGI issuing a written decision letter: 1. An initial interview must have occurred. 2. A completed application for No Fault benefits must have been received by SGI. 3. All available, relevant information with respect to the decision must have been received and reviewed by SGI. 4. The decision at issue must have received all necessary approvals within SGI. 5. It must be timely to render the decision at issue (e.g., it would not be timely to render a decision on scarring to a knee when the customer is to undergo knee surgery the following week). When SGI provides a decision When SGI provides the customer with a decision: The following steps should be followed when providing the customer with a decision: contact the customer to explain the rationale behind SGI s decision document this discussion on the file send the customer a detailed decision letter outlining SGI s decision The decision letter must include: the reason(s) for SGI s decision reference to the appropriate sections of the Act and regulations where necessary the appeal option. 101 days to request appeal or mediation 101 days to request appeal or mediation: SGI s policy is to provide the customer with the option to provide written notice requesting appeal or mediation within 101 days from the date of SGI s decision letter to allow adequate time for delivery of the decision letter. The 101 day appeal period allows for: the legislated 90 day appeal period (Act, s 191) delivery of the mail within 10 days (regulation 103) one additional day to allow the mail to be received by Canada Post prior to delivery The appeal period provided to the customer must be clearly identified in the body of any written decision letter outlining the customer s option to request an appeal or mediation. Note: Decision letters that are provided to the customer are to be sent by regular mail. 11.2.1 Decision Letter Requirements 2
Contact with the customer Contact with the customer: Regular communication with the customer is one of the most crucial elements of managing the claim. Ensure that you contact the customer at the onset and throughout the duration of the claim about any impending changes to the benefits they are receiving. During all steps leading up to and following a decision regarding benefit entitlement, ensure that you are explaining the process and keeping the customer informed. Notify the customer prior to issuing a written decision letter, as much as reasonably possible and when practical to do so. Manner of service Manner of service (Regulations, s 103): If a notice or document is required to be given, sent or otherwise served on a person, service may be effected by: personal service regular mail registered mail certified mail A notice or document served by regular, registered or certified mail is deemed to be effective if sent to the last known address of the person to whom notice is required to be sent. If a notice or document is served by regular mail, it is deemed to have been served on the tenth day following the date of its mailing. If a notice or document is served by registered or certified mail, it is deemed to be served on the day that Canada Post confirms is the day on which the notice or document was delivered to the address to which it is mailed. If a customer is represented by an agent who has provided SGI with proof of his or her authority to act as agent for the person, service on the agent constitutes service on the person. 11.2.1 Decision Letter Requirements 3
Reconsideration of SGI s decision Reconsideration of SGI s decision: SGI can at any time reconsider a decision it has made on a customer's file and, if warranted, change the initial decision. SGI may reconsider its decision either on its own authority or at the request of the customer. The following are examples of when SGI may reconsider its decision: New facts, evidence, or information are available. The customer s circumstances have changed. SGI believes a substantive or procedural error was made. SGI's decision contains an error in writing, calculating, typing or other clerical error. Note: The above is not an exhaustive list and is intended for example purposes only. There may be a number of reasons why SGI will reconsider a decision that has been made on a customer s claim file. If SGI reconsiders its decision in light of new information or an error, a new decision letter must be issued advising the customer of the change. 11.2.1 Decision Letter Requirements 4
11.2.2 The Appeal Process (11.2.2-01/2017) Effective January 1, 2017 Purpose Provides an overview of the appeal process and any related policies and procedures concerning SGI s decisions and appeals. Act 188-196 Insurer s Decisions and Appeals Regulations 84-100 Insurer s Decisions, Reviews and Appeals Overview of the appeal process Overview of the appeal process: SGI must provide written decisions outlining customer benefit entitlement, in accordance with section 189 of the Act. Every decision letter issued by SGI provides the customer with the appeal option and invites the customer to provide further information relevant to their claim. SGI will receive and review new information at any time during the appeal process. If the customer disagrees with SGI s decision, they have 101 days to request mediation or appeal to the appeal commission (Automobile Injury Appeal Commission) of the Court of Queen s Bench. If the customer mediates, they may choose from a list of mediators and the customer and SGI attend the mediation to discuss the issues. If there is no change to SGI s decision, the mediator will close the mediation by letter and the customer has a further 90 days to appeal to the appeal commission or Court of Queen s Bench. Upon receiving an application for appeal and the $75 fee, the appeal commission serves the Application for Appeal on SGI. SGI reviews the decision and, if the matter is not resolved, the file is forwarded to the SGI legal department for assignment. The appeal commission has a formal hearing before three members of the commission in most cases. In attendance are the SGI lawyer and, if applicable, the customer s lawyer or personal representative. Witnesses can give evidence in person, by telephone or by written report. Both the appeal commission and the Court of Queen s Bench render written decisions with respect to appeals. The decision is provided to both the customer and SGI. There is a limited right of appeal to the Court of Appeal which must be exercised within 30 days of a decision of either the appeal commission or the Court of Queen s bench. 11.2.2 The Appeal Process 1
Information required on an Appeal Summary Information required on an Appeal Summary: Upon notification that the customer has filed an appeal, an Appeal Summary must be completed prior to forwarding the file to the head office Claims Director (Injury) and SGI s legal department for review. Note: The Appeal Summary is subject to privilege and is not to be released. The Appeal Summary must contain the following types of information: customer name; claim number; accident date; injuries; date of appeal; customer s position for appeal (i.e., why the customer is appealing the decision); date of decision corresponding with appeal; if the appeal was filed within the appeal period; SGI s basis for the decision; and any other relevant information. SGI s basis for the decision: When completing the section detailing SGI s basis for the decision, the following types of information should be included in the Appeal Summary: a summary of evidence and documents that SGI relied on to make its decision how the evidence and documents that SGI relied on supports SGI s decision Examples of evidence or documents used by SGI to make a decision: income information medical information such as: practitioner reports consultation reports diagnostic testing results assessment reports; etc. medical consultant s reports Note: The above is not an exhaustive list and merely serves as an example of the types of information that SGI may consider when making a decision. Proceeding with appeal Proceeding with appeal: When a customer submits an application for appeal, SGI will be notified of this appeal. Upon notification of the appeal, an Appeal Summary will be completed. The branch director and/or manager will review the Appeal Summary. The file is then forwarded to the head office Claims Director (Injury) and SGI s legal department for review. 11.2.2 The Appeal Process 2
Injury claim handling during appeal Injury claim handling during appeal: The customer s injury claim is to continue to be adjudicated by the Personal Injury Representative (PIR) while the file is going through the appeal process. Decision provided by the appeal commission Decision provided by the appeal commission: Once SGI receives a decision from the appeal commission, the decision is reviewed by the head office Claims Director (Injury). If SGI is unsuccessful at appeal, the head office Claims Director (Injury), in consultation with SGI s legal department will determine if SGI will appeal the decision to the Court of Appeal. An appeal to the Court of Appeal must be completed within 30 days of the decision of the Court of Queen s Bench or appeal commission. Following review of an appeal commission or Court of Queen s Bench decision by the Claims Director (Injury), the file will be returned with direction on how to proceed with the management of the file. PJI if appeal is overturned Pre-judgment interest if appeal is overturned: SGI will pay pre-judgment interest (PJI) when a decision is changed at appeal or mediation. PJI may be paid when the decision involves: income replacement benefits living assistance benefits child care benefits permanent impairment benefits expenses incurred by the customer Note: The above list is not exhaustive and PJI may apply in other circumstances. In instances where a PJI calculation is required: contact the IRB unit to obtain a PJI calculation provide the IRB unit with an explanation of the benefits to be paid provide the IRB unit with the start date for the calculation of the PJI The IRB unit will review the PJI rate in place over the period that the benefit is payable and provide a PJI calculation. 11.2.2 The Appeal Process 3
Reimbursement of appeal fee Reimbursement of appeal fee: The appeal commission collects the $75 appeal fee, and will refund this fee if the customer is successful in their appeal. SGI is not responsible for the reimbursement of the $75 appeal fee where the appeal has been heard. The appeal commission will not refund the fee if the customer withdraws their appeal. In these instances, SGI will reimburse the customer the $75 fee if the customer withdraws their appeal. For example, if the customer initially appealed the benefit thereby causing SGI to change its decision and the customer, in turn, to withdraw the appeal, SGI will reimburse the customer the $75 appeal fee. Submission of the Application for Appeal Submission of the Application for Appeal: SGI does not send applications for appeal to the appeal commission on behalf of a customer. The appeal commission date stamps correspondence received by their office to determine if an application is received within the appeal period. If a customer submits a completed application for appeal to SGI, advise the customer that this application cannot be submitted by SGI to the appeal commission on their behalf. If the appeal date in the decision letter falls on a weekend or statutory holiday, the appeal period will be extended to the next business day. Note: The Automobile Injury Appeal Commission is an independent, quasi-judicial administrative tribunal responsible for hearing No Fault benefits appeals. 11.2.2 The Appeal Process 4
11.2.3 Mediation (11.2.3-01/2017) Effective January 1, 2017 Purpose Provides an overview of the mediation process and any related policies and procedures concerning SGI s decisions and mediation. Act 188-196 Insurer s Decisions and Appeals Regulations 84-100 Insurer s Decisions, Reviews and Appeals Overview of the mediation process Overview of the mediation process: SGI must provide written decisions outlining customer benefit entitlement, in accordance with section 189 of the Act. Every decision letter issued by SGI provides the customer with mediation as an option and invites the customer to provide further information relevant to their claim. SGI will receive and review new information at any time during the appeal or mediation process. If the customer disagrees with SGI s decision, they have 101 days to request mediation or appeal to the appeal commission (Auto Injury Appeal Commission). Mediation is an optional process. If the customer requests mediation, they must state the issues which are to be the subject of mediation. If the customer mediates, they may choose from a list of mediators and the customer and SGI attend the mediation to discuss the issues. If the customer and SGI cannot agree on a mediator within 30 days of SGI receiving a written request for mediation, the customer or SGI may apply to the manager of mediation services to appoint a mediator. A mediator will attempt to assist the customer and SGI to settle the issues that are the subject of mediation, but the mediator cannot make any decision that is binding. If there is no change to SGI s decision, the mediator will close the mediation by letter and the customer has a further 90 days to appeal to the appeal commission or Court of Queen s Bench. The 90 day period runs from the date of the mediator s letter concluding mediation. Request for mediation Requests for mediation: When a customer wishes to mediate a decision, the customer advises SGI and provides a payment of the $54 (2016) fee. This fee (i.e., cheque or money order) with the customer s written request for mediation is then forwarded to Claims Support Services with a copy of the decision letter(s) which is the subject of mediation. All other fees associated with mediation are paid by SGI. Claims Support Services provides the customer with a list of mediators to choose from. The customer is instructed to select three mediators from the list provided within 30 days or a mediator will be chosen by SGI. From the three mediators selected by the customer, SGI will select one mediator to conduct mediation. 11.2.3 Mediation 1
The mediator selected will be advised by SGI in writing of the request for mediation. The mediator, in conjunction with the customer and SGI, will arrange a date, time, and location for the mediation to take place. It is also the mediator s duty to advise the customer and SGI of the requirements regarding materials to be filed prior to mediation taking place. Selection of a mediator: When mediation is selected, SGI provides a list of mediators drawn from the current Directory of Mediators published by Conflict Resolution Saskatchewan Inc. (CRSI). Additional information about the mediators and their qualifications may be found at: Conflict Resolution Saskatchewan Inc. Phone: 306-565-3939, or toll free at 1-866-565-3938 Fax: 306-586-6711 Mailing address - P.O. Box 3765 Regina, SK S4P 3M8 Email - admin@conflictresolutionsk.ca Online - www.conflictresolutionsk.ca Subsequent requests for mediation Subsequent requests for mediation: If the customer has previously requested mediation, but the mediation has not been held at the time that the customer makes a second mediation request regarding a separate issue, SGI will not charge the customer a second mediation fee. The customer will still be required to provide a written request for mediation and the request for mediation for the subsequent SGI decision must still fall within the mediation period outlined in the decision letter. The same mediator will be asked to address both issues at the time that mediation is held. If it is not timely or practical (e.g., there is not adequate time to prepare to mediate the second issue) for the mediator to address both issues when mediation is held, a second date may be scheduled to address the second issue. Who is to attend mediation Who is to attend mediation: The following individuals may attend mediation: the customer and their personal or legal representative the Personal Injury Representative (PIR) and the PIR III or Adjuster III the mediator Mediation accounts Mediation accounts GST exempt: Mediation accounts are forwarded to SGI for payment. The amount of any GST is to be deducted from the mediation accounts at the time of payment as SGI is GST exempt. 11.2.3 Mediation 2
Mediator to close mediation in writing Mediator to close mediation in writing: When mediation closes, a letter must be sent by the mediator to the customer advising that mediation is closed. The mediation must be closed in writing and the customer notified of the 90 day period following the conclusion of mediation to pursue an appeal with the appeal commission or Court of Queen s Bench. 11.2.3 Mediation 3