An Ontario tribunal sided with Allstate, ruling its denial letters met statutory standards and rejecting a claimant's bid to escape the minor injury cap.
The decision, released July 17, 2026, by the Licence Appeal Tribunal, turns on how much detail a denial letter must contain - and where the burden of proof sits.
The dispute arose after the claimant was injured in an accident on April 15, 2024, and sought accident benefits. Allstate determined the injuries were minor and declined to fund two treatment plans that fell outside the $3,500 Minor Injury Guideline limit. At issue were $5,126.46 in chiropractic services and $2,144.93 for a psychological assessment.
Rather than argue the injuries themselves warranted removal from the MIG, the claimant built her case around the insurer's paperwork. She contended the denial letters used boilerplate language, failed to engage with the medical information in her treatment plan forms, and that the insurer improperly sought her family doctor's clinical notes and diagnostic reports.
The tribunal was not persuaded. It found the applicant had not met her onus to prove, on a balance of probabilities, that her accident-related injuries fell outside the MIG. Any deficiencies she alleged in the denial letters, the adjudicator noted, did not help her meet that burden. The applicant had led no medical evidence supporting a non-minor injury.
On the letters themselves, the tribunal found each notice compliant with section 38(8) of the Statutory Accident Benefits Schedule. That provision requires an insurer to give medical and other reasons for refusing a plan within 10 business days. The adjudicator held that adjusters need not provide a medical opinion, nor be "held to a standard of perfection."
The insurer's requests for additional records also survived scrutiny. The tribunal found Allstate was entitled to seek family doctor notes, specialists' reports and diagnostic information to assess whether the injuries fell outside the guideline, and that doing so did not breach section 38(8).
The claimant advanced two further arguments that the tribunal rejected. She said the guideline could only be assessed alongside the disputed treatment plans, not on its own - a position the adjudicator found unsupported by authority. She also argued that section 54 confined the insurer to the reasons stated in its denial letters, barring new submissions at the hearing. The tribunal disagreed, finding nothing in that provision limits an insurer's arguments to its correspondence.
With the claimant remaining subject to the MIG, the treatment plans were not payable. The tribunal also declined to award interest, as no benefits were overdue, and refused an award under section 10 of Regulation 664, which allows up to 50 per cent of benefits payable where an insurer unreasonably withholds or delays payment. With nothing withheld, the tribunal found no basis for an award.
For insurers, the ruling reinforces that a denial letter need not read like a medical report to stand. For claims professionals, it underscores that an applicant challenging a refusal still carries the burden of proving the injury itself.
