Executive Summary: Key Legal and Evidentiary Issues

• Interpretation of the post-104-week test for income replacement benefits (IRBs) under s. 6(2)(b) of the Statutory Accident Benefits Schedule (Schedule) was central to the dispute.

• The evidentiary burden rested on the insured to prove a complete inability to engage in any employment for which she was reasonably suited by education, training, or experience.

• Consideration of whether suitable alternative employment must be in a competitive, real-world setting and comparable in status and remuneration was debated.

• Medical and vocational evidence regarding the insured’s ability to work in alternative roles was pivotal.

• The relevance and weight of factors such as status, reward, and nature of alternative employment were analyzed as part of a contextual, evidence-based assessment.

• The appellate court affirmed that these factors are not stand-alone requirements but must inform the overall analysis of entitlement to post-104-week IRBs.

Facts of the case

Shelley Rumball was involved in a motor vehicle accident on December 28, 2014. At the time, she worked as an educational assistant and had recently started a business as a wedding planner. After the accident, Rumball returned to her educational assistant position in February 2015 but stopped working again in May 2015, claiming she could not perform her job due to her injuries. She sought statutory accident benefits (SABs), specifically income replacement benefits (IRBs), from her insurer, Traders General Insurance Company, for her inability to work both before and after the 104-week mark following her accident.

Rumball’s claim was based on her assertion that she suffered from chronic pain, psychological impairments, and other health issues resulting from the accident, making her unable to work in any capacity. She provided medical evidence from her psychiatrist and a chronic pain specialist, both supporting her claim of disability. Traders, however, presented expert evidence indicating that Rumball’s injuries were minor and that she was capable of returning to work as an educational assistant, wedding planner, or in other suitable roles. The evidence also showed that Rumball had performed some wedding planning work, volunteered, and cared for her terminally ill father after the accident.

Policy terms and clauses at issue

The dispute centered on the interpretation and application of s. 6(2)(b) of the Statutory Accident Benefits Schedule, which governs entitlement to IRBs after the first 104 weeks of disability. This provision requires that, to qualify for continued IRBs, an insured must suffer a “complete inability to engage in any employment or self-employment for which he or she is reasonably suited by education, training or experience.” The legal debate was whether this test should include only the insured’s ability to work in a competitive, real-world setting, and whether the alternative employment must be comparable in status and remuneration to the pre-accident job.

Outcome and reasoning

The Licence Appeal Tribunal (LAT) initially found that Rumball was entitled to IRBs up to the 104-week mark but not beyond, as she had not demonstrated a complete inability to engage in any suitable employment. The Divisional Court upheld this decision, confirming that the correct test had been applied and that the factors of status, remuneration, and real-world competitiveness were relevant but not stand-alone requirements.

On further appeal, the Court of Appeal for Ontario affirmed the lower courts’ decisions. The appellate court clarified that s. 6(2)(b) requires a contextual, evidence-based analysis, considering all relevant factors—including the nature, status, and reward of alternative employment—but does not demand that these factors be met as independent requirements. The court found that the adjudicator had properly weighed the evidence and applied the correct legal test. Rumball had not met her burden to prove a complete inability to work in any job for which she was reasonably suited by education, training, or experience. The court dismissed the appeal and awarded costs to Traders General Insurance Company in the agreed amount of $7,000, as the successful party. If there were any additional monetary awards or costs, they could not be determined from the decision.