PART VII ACCIDENT AND SICKNESS INSURANCE
Statutory conditions
300 Subject to section 301, the conditions set out in this section shall be deemed to be part of every contract other than a contract of group insurance or of creditor’s group insurance, and shall be printed in English or French in or attached to the policy forming part of such contract with the heading “Statutory Conditions” or “Conditions légales”, as may be appropriate, and no variation or omission of or addition to any statutory condition not authorized by section 301 is binding on the insured. STATUTORY CONDITIONS The Contract 1. (1) The application, this policy, any document attached to this policy when issued, and any amendment to the contract agreed upon in writing after the policy is issued, constitute the entire contract, and no agent has authority to change the contract or waive any of its provisions. (2) Repealed: 2012, c. 8, Sched. 23, s. 42 (2). Copy of Application (3) The insurer shall, upon request, furnish to the insured or to a claimant under the contract a copy of the application. Material Facts 2. No statement made by the insured or person insured at the time of application for this contract shall be used in defence of a claim under or to avoid this contract unless it is contained in the application or any other written statements or answers furnished as evidence of insurability. Changes in Occupation 3. (1) If after the contract is issued the person insured engages for compensation in an occupation that is classified by the insurer as more hazardous than that stated in this contract, the liability under this contract is limited to the amount that the premium paid would have purchased for the more hazardous occupation according to the limits, classification of risks and premium rates in use by the insurer at the time the person insured engaged in the more hazardous occupation. (2) If the person insured changes his or her occupation from that stated in this contract to an occupation classified by the insurer as less hazardous and the insurer is so advised in writing, the insurer shall either, (a)  reduce the premium rate; or (b)  issue a policy for the unexpired term of this contract at the lower rate of premium applicable to the less hazardous occupation, according to the limits, classification of risks, and premium rates used by the insurer at the date of receipt of advice of the change in occupation, and shall refund to the insured the amount by which the unearned premium on this contract exceeds the premium at the lower rate for the unexpired term. Relation of Earnings to Insurance 4. (1) Where the benefits for loss of time payable hereunder, either alone or together with benefits for loss of time under another contract, exceed the money value of the time of the person insured, the insurer is liable only for that proportion of the benefits for loss of time stated in this policy that the money value of the time of the person insured bears to the aggregate of the benefits for loss of time payable under all such contracts and the excess premium, if any, paid by the insured shall be returned to the insured by the insurer. (2) The other contract referred to in subcondition (1) may include, (a)  a contract of group accident and sickness insurance; or (b)  a life insurance contract whereby the insurer undertakes to pay insurance money or to provide other benefits in the event that the person whose life is insured becomes disabled as a result of bodily injury or disease. Termination by Insured 5. The insured may at any time request that this contract be terminated and the insurer shall, as soon as practicable after the insured makes the request, refund the amount of premium actually paid by the insured that is in excess of the short rate premium calculated to the date of the request according to the table in use by the insurer at the time of the termination. Termination by Insurer 6. (1) The insurer may terminate this contract at any time by giving written notice of termination to the insured and by refunding concurrently with the giving of notice the amount of premium paid in excess of the proportional premium for the expired time. (2) The notice of termination may be given in the following ways: 1.  It may be personally delivered to the insured. 2.  It may be delivered by prepaid courier to the latest address of the insured on the records of the insurer if there is a record by the person who has delivered it that the notice has been sent. 3.  It may be sent by registered mail to the latest address of the insured on the records of the insurer. (3) Where the notice of termination is personally delivered or delivered by prepaid courier to the insured, five days notice of termination shall be given and, if delivered by prepaid courier, the five-day period begins on the day there is a record by the person who delivered it that the notice has been sent. Where it is mailed to the insured, 15 days notice of termination shall be given, and the 15-day period begins on the day the registered letter or notification of it is delivered to the insured’s address. Notice and Proof of Claim 7. (1) The insured or a person insured, or a beneficiary entitled to make a claim, or the agent of any of them, shall, (a)  give written notice of the claim to the insurer in one of the following ways, not later than 30 days from the date a claim arises under the contract on account of an accident, sickness or disability: (i)  by personal delivery or by sending it by registered mail to the head office or chief agency of the insurer in the Province, (ii)  by personal delivery to an authorized agent of the insurer in the Province, or (iii)  by delivery by electronic means; (b)  within ninety days from the date a claim arises under the contract on account of an accident, sickness or disability, furnish to the insurer such proof as is reasonably possible in the circumstances of the happening of the accident or the commencement of the sickness or disability, and the loss occasioned thereby, the right of the claimant to receive payment, his or her age, and the age of the beneficiary if relevant; and (c)  if so required by the insurer, furnish a satisfactory certificate as to the cause or nature of the accident, sickness or disability for which claim may be made under the contract and as to the duration of such sickness or disability. Failure to Give Notice or Proof (2) Failure to give notice of claim or furnish proof of claim within the time prescribed by this statutory condition does not invalidate the claim if, (a)  the notice or proof is given or furnished as soon as reasonably possible, and in no event later than one year from the date of the accident or the date a claim arises under the contract on account of sickness or disability if it is shown that it was not reasonably possible to give notice or furnish proof within the time so prescribed; or (b)  in the case of the death of the person insured, if a declaration of presumption of death is necessary, the notice or proof is given or furnished no later than one year after the date a court makes the declaration. Insurer to Furnish Forms for Proof of Claim 8. The insurer shall furnish forms for proof of claim within fifteen days after receiving notice of claim, but where the claimant has not received the forms within that time the claimant may submit his or her proof of claim in the form of a written statement of the cause or nature of the accident, sickness or disability giving rise to the claim and of the extent of the loss. Rights of Examination 9. As a condition precedent to recovery of insurance money under this contract, (a)  the claimant shall afford to the insurer an opportunity to examine the person of the person insured when and so often as it reasonably requires while the claim hereunder is pending; and (b)  in the case of death of the person insured, the insurer may require an autopsy subject to any law of the applicable jurisdiction relating to autopsies. When Money Payable Other Than for Loss of Time 10. All money payable under this contract, other than benefits for loss of time, shall be paid by the insurer within sixty days after it has received proof of claim. When Loss of Time Benefits Payable 11. The initial benefits for loss of time shall be paid by the insurer within thirty days after it has received proof of claim, and payment shall be made thereafter in accordance with the terms of the contract but not less frequently than once in each succeeding sixty days while the insurer remains liable for the payments if the person insured when required to do so furnishes before payment proof of continuing disability. 12. Repealed:  2002, c. 24, Sched. B, s. 39 (7). R.S.O. 1990, c. I.8, s. 300; 2002, c. 18, Sched. H, s. 4 (29); 2002, c. 24, Sched. B, s. 39 (7); 2012, c. 8, Sched. 23, s. 42 (1, 2, 4, 5); 2013, c. 2, Sched. 8, s. 23; 2019, c. 7, Sched. 33, s. 8 (1); 2020, c. 36, Sched. 22, s. 8; 2021, c. 40, Sched. 14, s. 5. Section Amendments with date in force (d/m/y) 2002, c. 18, Sched. H, s. 4 (29) - 30/04/2007; 2002, c. 24, Sched. B, s. 39 (7) - 01/01/2004 2012, c. 8, Sched. 23, s. 42 (1, 2, 4, 5) - 01/07/2016 2012, c. 8, Sched. 23, s. 42 (3) - no effect - see 2013, c. 2, Sched. 8, s. 23 (3) - 01/07/2016 2013, c. 2, Sched. 8, s. 23 (1-3) - 01/07/2016 2019, c. 7, Sched. 33, s. 8 (1) - 01/01/2022; 2019, c. 7, Sched. 33, s. 8 (2) - no effect - see 2020, c. 36, Sched. 22, s. 9 (2) - 08/12/2020 2020, c. 36, Sched. 22, s. 8 - 01/01/2022 2021, c. 40, Sched. 14, s. 5 - 01/01/2022