Executive Summary: Key Legal and Evidentiary Issues

• Beneva bore the burden of proving that the insured's medical condition had changed once it terminated disability benefits it had previously recognized.
• Orthopedic expert evidence established, on a balance of probabilities, that the plaintiff's physical condition no longer prevented her from holding gainful employment under the policy definition.
• No contemporaneous medical evidence supported the insurer's position that the plaintiff's psychiatric condition had resolved when benefits ceased on January 31, 2020.
• Exclusion clauses 7.6.6 and 7.6.7, requiring continuous medical care and adequate treatment, prima facie applied because the plaintiff had stopped her medication and psychiatric follow-up.
• The Court set the exclusion aside because the plaintiff's refusal of treatment was itself a symptom of her bipolar disorder (anosognosia), making it unreasonable to impose a duty of medical follow-up on her.
• Claims for moral damages, punitive damages, and reimbursement of legal fees failed, as no fault, bad faith, or abuse of procedure by the insurer was proven.

Facts of the case

Geneviève Marie Clémence Gauthier worked in 2013 as a medical resident at the Centre hospitalier universitaire de Sherbrooke and was covered by a group insurance contract between La Capitale assurances et gestion du patrimoine inc. (which became Beneva in 2022) and the Fédération des médecins résidents du Québec, in force since January 1, 2013. On January 4, 2013, she stopped working for medical reasons, with a diagnosis of bipolar affective disorder type 1 with rapid cycling and mixed phase. Her employer compensated her for the first 105 weeks, after which the insurer began paying disability benefits on January 4, 2015 under the first prong of the policy's definition of total disability. On October 6, 2017, the insurer advised her that she did not meet the second prong of the definition and that benefits would end. Following several review requests and a complaint, the insurer reversed course on February 19, 2019, recognizing that her condition met the definition of total disability and paying benefits retroactively from January 4, 2018. Benefits continued until January 31, 2020, with an interruption between August 1 and November 7, 2019 (later reimbursed) after she missed an orthopedic assessment. On January 24, 2020, relying on the expert report of orthopedic surgeon Dr. Boivin, the insurer advised her that benefits would end on January 31, 2020. The plaintiff, self-represented, sought reinstatement of her benefits retroactive to February 1, 2020, a lump-sum payment of future benefits until age 65 (or alternatively monthly payments), $75,000 in moral damages, $200,000 in punitive damages, and $17,000 in legal fees incurred before the proceedings.

Policy terms and contractual clauses at issue

Clause 1.15 of the contract defined total disability in two stages: during the first 60 months, an incapacity rendering the member totally unable to perform the usual tasks of their employment; after that period, an incapacity effectively preventing the member from engaging in any gainful activity providing at least 80% of the salary earned at the onset of disability, for which the member has reasonable aptitudes given their education, training, or experience. Also central were the exclusion clauses: clause 7.6.6, excluding benefits for any period during which the member is not under the continuous care of a physician unless the physician attests, to the insurer's satisfaction, that the condition is stable, and clause 7.6.7, excluding benefits for any period during which the member does not receive the pertinent and adequate care required for the illness causing the total disability and recommended by the treating physician.

The court's reasoning and analysis

Justice Sophie Leblanc of the Superior Court of Québec noted that once an insurer has recognized a disability, the burden shifts to the insurer to prove, on a balance of probabilities, that the insured no longer meets the contractual criteria. Regarding the physical condition, the Court found the evidence preponderant: the expert reports of Dr. Boivin (2019) and Dr. Cournoyer (2025), together with the employability assessment of counsellor Sandy Vignola Pétrin, demonstrated that the plaintiff's orthopedic condition did not prevent her from holding gainful employment, and the rheumatological expertise of Dr. Fitzcharles found no evidence of an underlying rheumatological condition. The psychiatric condition was another matter. The January 24, 2020 termination notice made no mention of it, and the most contemporaneous medical evidence — a January 23, 2018 assessment by Dr. Morin describing the bipolar disorder as asymptomatic but precarious — did not establish that the incapacity had resolved. The insurer conducted no investigation of her psychiatric state beyond her own assertions that she was doing better since stopping her medication, which the Court held insufficient to discharge its burden. Turning to the exclusions, the Court accepted that the insurer had prima facie grounds to invoke them, since the plaintiff had ceased all medication in November 2016 and all psychiatric follow-up. The burden then shifted back to the plaintiff to establish an exception. Relying on the March 2025 expert report of psychiatrist Dr. Gil — the insurer's own expert — the Court found that the plaintiff's denial of her illness and refusal of treatment stemmed from anosognosia, a symptom of her active bipolar disorder. Imposing a duty of medical follow-up on someone whose illness prevents her from recognizing that illness was held unreasonable; her refusal of care was inseparable from the very risk insured against. The Court added that the insurer had known since October 5, 2017 that she had ceased treatment yet still recognized her entitlement to benefits, and could not later invoke that same absence of treatment to end coverage. Dr. Gil further confirmed that she remained affected by a severe, chronic, and disabling psychiatric condition. The lump-sum request was refused because the contract provided only for monthly payments. As for damages, the Court held that the mere cessation of benefits, even if unjustified, is not in itself a fault; the insurer had acted prudently and diligently, its processing delays were not unreasonable, the plaintiff's own incomplete collaboration contributed to delays, and no bad faith or intentional conduct was shown, so the claims for moral and punitive damages failed. The claim for legal fees was dismissed since no abuse of procedure was established, and the Court also observed that the supporting exhibits totalled $14,400 rather than the $17,000 claimed.

Ruling and overall outcome

In its judgment of June 23, 2026, the Court granted the plaintiff's action in part, making Ms. Gauthier the successful party on the central issue. It declared her totally disabled within the meaning of the insurance contract retroactively to February 1, 2020, condemned Beneva to pay all unpaid disability benefits since that date with interest at the legal rate and the additional indemnity under article 1619 of the Civil Code of Québec, and ordered the insurer to pay her monthly benefits going forward for as long as her disability continues, with legal costs against the defendant. Her claims for moral damages, punitive damages, and reimbursement of legal fees were all rejected. No exact total monetary amount can be determined from the judgment, as it does not specify the monthly benefit amount or quantify the accumulated arrears owed.