A flawed denial notice has cost Allstate. Ontario's Licence Appeal Tribunal ordered the insurer to pay for a workplace assessment it had refused.
The dispute reached the Licence Appeal Tribunal - Automobile Accident Benefits Service after the applicant, injured in an automobile accident on May 6, 2021, sought statutory accident benefits and was denied by Allstate Insurance Company of Canada. The insurer had removed him from the Minor Injury Guideline on January 14, 2022. Adjudicator Aric Bhargava decided the matter on written submissions and released the amended decision on June 25, 2026.
The notice point proved decisive on one item. Allstate's explanation of benefits, dated June 29, 2023, denied a $2,200 workplace assessment, noting only that the goods or service was not covered and that post-104 assessments were not payable under section 25. Bhargava found the letter never referred to the applicant's injuries and gave no medical reasons. He concluded that "an unsophisticated person would not understand why the benefit is being denied."
Because the notice failed section 38(8) of the Statutory Accident Benefits Schedule, and no evidence showed the defect was ever cured, the adjudicator held the workplace assessment payable once incurred and invoiced. Section 38(8) requires an insurer to give the medical and other reasons for a denial within 10 business days of receiving a treatment plan. Under section 38(11), an insurer that misses that standard must fund the goods and services for the gap period and cannot take the position that the Minor Injury Guideline applies.
The larger awards turned on the merits rather than the notice. Bhargava found a $2,200 occupational therapy assessment and occupational therapy treatment plans of $7,245.32 and $3,916.31 reasonable and necessary, relying on the applicant's family physician's records and a functional cognitive assessment documenting ongoing memory, concentration and cognitive complaints. He was not persuaded by the insurer's section 44 occupational therapy reports, which treated the injuries as soft tissue and characterized the treatment as addressing unrelated problems.
The applicant lost the balance of his claims. The adjudicator denied a $4,587 outstanding occupational therapy balance, two physiotherapy plans of $1,273.50 and $3,273.00, three psychological-service preparation fees of $448.80 each, a $2,200 physiatry assessment and a $2,200 psychological assessment. His reasons ranged from unexplained treatment gaps to the Professional Services Guideline's limits on preparation fees, and a finding that a fresh psychological assessment duplicated one already approved.
Interest applies to the benefits awarded under section 51 of the Schedule.
For claims professionals, the decision draws a line the tribunal has drawn before: the substance of a treatment plan is argued on the medical evidence, but the sufficiency of a denial letter is judged on its own terms - and a notice that names a Schedule provision without explaining the medical reasons can put a benefit in play regardless of the underlying merits.
