After being deprived of benefits since January 24, 2020, the plaintiff has prevailed before the Superior Court of Quebec. The insurer had conducted no investigation into its insured's psychiatric condition and therefore could not terminate her disability insurance benefits, the court concluded.

The plaintiff, Geneviève Marie Clémence Gauthier, sought reinstatement of her benefits retroactive to February 1, 2020. The court ruled in her favour, declaring her totally disabled within the meaning of the insurance contract.

The insurer must also continue paying monthly benefits under the same contract for as long as her disability persists. The court dismissed the claims for damages, moral damages and punitive damages against the defendant insurer, Beneva.

Justice Sophie Leblanc heard arguments from the parties in January 2026 in the judicial district of Gatineau. Her decision was rendered on June 23, 2026, and published in French only.

Maurice Charbonneau, a lawyer with Groupe Trivium, brought this decision to the attention of Insurance Portal. He highlighted the exceptional nature of this disability insurance judgment "because of the quality of the analysis of the situation from the various legal perspectives that must be considered." He noted that the plaintiff represented herself in the litigation against the insurer.

The contract and the disability

In 2013, Gauthier was working as a medical resident at the Centre hospitalier universitaire de Sherbrooke (CHUS). Her salary was governed by an agreement between the Fédération des médecins résidents du Québec (FMRQ) and the Ministère de la Santé et des Services sociaux.

She was insured under a group insurance contract between the FMRQ and La Capitale Insurance and Financial Services (which became Beneva in 2022). On January 4, 2013, she stopped working for medical reasons. "The diagnosis was rapid-cycling bipolar I affective disorder with mixed features."

For the first 105 weeks following the date she stopped working, she received compensation from her employer. The insurer subsequently took over under clause 1.15 of the insurance contract, which defines total disability. The 60-month period of disability ended on January 4, 2018.

As early as October 6, 2017, the insurer notified Gauthier that her condition no longer met the definition of total disability. It considered her capable of engaging in any gainful employment that would provide her with at least 80% of the income she was earning at the onset of her disability.

On February 19, 2019, following a request for review, benefits were reinstated retroactively through March 31, 2019. Benefits were then paid from April 2019 until the end of January 2020.

Benefits were interrupted between August 1 and November 7, 2019, because the plaintiff missed an appointment for an orthopedic assessment requested by the insurer. The insurer subsequently paid the benefits retroactively.

On January 24, 2020, the insurer notified Gauthier that she no longer met the definition of total disability and that her benefits would terminate on January 31, 2020.

The legal principles

The plaintiff argued that her physical medical condition met the criteria for insurance coverage. The defendant disputed this allegation and further maintained that it was justified in terminating benefits related to her psychiatric condition because Gauthier refused or neglected to receive the care required by her condition. According to the insurer, this allowed it to invoke the contractual exclusions concerning her obligation to undergo medical follow-up and treatment.

The court noted that the policy was a contract of adhesion and that the provisions distinguishing short-term from long-term disability were standard clauses. The contract was subject to the same rules of interpretation as any other contract, as set out in articles 2389 et seq. of the Civil Code of Québec.

The insured had demonstrated that her condition constituted a disability as defined in the contract. Once that disability was recognized, the insurer bore the burden of proving, on a balance of probabilities, that the insured's condition had changed or that the exclusion clauses applied.

Physical health problems

In answering the first question at issue, Justice Leblanc found that the disability insurance coverage applied to the plaintiff and entitled her to receive benefits. The judgment summarizes the decisions made by the insurer between October 2017 and January 2020, as well as the plaintiff's challenges to those decisions.

To understand the insurer's reasoning during that period, the court referred to administrative notes in the insurer's file. On September 14, 2017, a psychiatrist serving as a medical advisor to the insurer reviewed the file. She acknowledged that Gauthier was unable to work as a medical resident but considered her capable of performing any other job, noting that the insured "was not mitigating her damages."

On June 4, 2019, the insurer informed Gauthier that payment of benefits was conditional on an assessment by an orthopedic surgeon. The surgeon submitted an expert report concluding that Gauthier had no functional limitations preventing her from working.

On May 31, 2018, during a conversation with her claims representative, the insured stated that she was unable to perform any job because of her physical health problems. Gauthier subsequently gave birth to twins in July 2019 and reported rheumatological problems. This condition was not medically substantiated.

Her orthopedic condition was also examined extensively. Beginning in January 2018, she provided information about chronic injuries affecting her right hip, right shoulder and lumbar vertebrae. Magnetic resonance imaging confirmed these problems.

The insurer's medical advisor acknowledged certain limitations and listed movements she should avoid but specified that these limitations were not incompatible with office work. He recommended an orthopedic assessment.

On December 14, 2018, a dispute resolution advisor for the insurer noted that Gauthier's medical file had documented significant shoulder and hip pain since January 2017. "The pain can cause a very high level of stress that affects her mental health."

In February 2019, the insurer reinstated benefits, thereby acknowledging that her orthopedic medical condition was disabling, subject to continued assessment of that condition.

Lack of follow-up

The most recent medical evidence relating to the termination of benefits was a psychiatric assessment conducted two years earlier. The psychiatrist met Gauthier for the first time because Gauthier had expressed dissatisfaction with her treating physician. The report from the January 23, 2018, appointment "does not confirm to the insurer that the disability resulting from the illness has resolved. On the contrary, it raises concerns about the instability of her symptoms."

Even though the insured maintained that she no longer suffered from the condition, the obligation remained, the court added. The insurer had a duty to determine whether the plaintiff's psychological incapacity met the contractual definition of total disability.

"The contract binding the parties reflects their common intention to protect the insured and provide financial security in the event that their health prevents them from working," Justice Leblanc recalled. The insurance contract must be interpreted broadly and liberally in favour of the insured party adhering to the contract, according to legal scholars Hubert Reid and Simon Reid in a legal treatise.

The insurer failed to establish, on a balance of probabilities, that the illness underlying the disability had resolved, even though the plaintiff stated that she had improved since discontinuing her medication. Consequently, the termination of benefits was unjustified.

The alleged exclusion

The insurer argued that the psychiatric condition was excluded from insurance coverage because the plaintiff had not undergone medical follow-up or treatment for that condition since April 2017. "This position, however, is not supported by the evidence," the court wrote.

The December 14, 2018, note mentioned above contained a lengthy list of observations concerning the insured. It revealed that the insurer recognized the incapacity resulting from the plaintiff's psychiatric diagnosis and that this condition prevented her from engaging in any gainful employment, as provided under the second part of the coverage set out in clause 1.15.

The insurer sought to establish that the plaintiff could work at the time she refused to follow her treatment. In doing so, Beneva "disregards the findings of the expert assessment, which concludes that she suffers from psychiatric health disorders that lead her to deny her illness and, consequently, refuse treatment."

In a ruling issued in 2000, the Supreme Court of Canada reiterated that "the duty to mitigate damages is an obligation of means, not of result." Its interpretation must be based on an assessment of the circumstances.

Involuntary denial

The insurer's psychiatric expert confirmed that the plaintiff's denial of her psychiatric condition and refusal of treatment were linked to her illness. He also noted that the plaintiff still suffered from the illness when he examined her in March 2025.

According to the court, the plaintiff's psychiatric condition must serve as the starting point for analyzing the circumstances explaining her refusal of treatment. In his report on the plaintiff's 2025 examination, the psychiatric expert confirmed that it is common for a person suffering from bipolar disorder "to deny their condition and refuse treatment."

Through the involuntary denial of her illness, "the plaintiff demonstrates that the exclusion clause must be set aside. She is unable to mitigate her damages because her refusal of care is a symptom of the illness that prevents her from complying with medical follow-up and treatment for that illness."

The insurer's psychiatric expert analyzed the history of her bipolar disorder. Despite certain brief periods during which she was able to function in her daily activities, her medical history was marked by serious health problems and behaviours associated with bipolar disorder. "The plaintiff's refusal of treatment is inseparable from the very symptoms associated with this illness," Justice Leblanc wrote.

The court therefore found that the plaintiff was entitled to coverage under the contract and must receive disability benefits retroactive to February 1, 2025.

Claims dismissed

The plaintiff sought to have her future benefits paid in a single lump sum. This option was not provided for in the contract, and the court dismissed the claim.

Gauthier sought $75,000 in moral damages for the periods during which the insurer stopped paying her benefits. Justice Leblanc devoted seven of the 38 pages of her decision to analyzing this part of the claim before dismissing it.

In the circumstances of the case, the court found that the termination of benefits did not constitute a fault on Beneva's part. On several occasions, the plaintiff had informed the insurer that she no longer suffered from the psychological problems for which she was receiving benefits. She subsequently stated that her inability to work stemmed from her physical health problems.

The court also dismissed the plaintiff's claim for $200,000 in punitive damages. Nothing in the evidence supported a finding that the insurer had acted in bad faith in handling the disability insurance claim. It had not acted with recklessness, imprudence or gross negligence.

As for the $17,000 in legal fees incurred by the plaintiff before proceedings were instituted, the grounds for this claim were not detailed in the originating application. The supporting documents submitted for this claim totalled $14,400. Case law establishes that only an abuse of process can give rise to reimbursement of legal fees. The court dismissed this claim.

The benefits must bear interest at the legal rate, together with the additional indemnity provided for under article 1619 of the Civil Code of Québec, calculated from the due date of each benefit payment. The insurer must also pay the court costs.