An Ontario tribunal sided with Allstate on most accident benefits claims, ruling clinic billing for administrative time inside treatment sessions was not payable.
The Licence Appeal Tribunal released its decision in Tho v Allstate Insurance Company of Canada, 2026 CanLII 51004 (ON LAT) on May 28, 2026, resolving a statutory accident benefits dispute arising from a July 31, 2022 automobile accident. Adjudicator Amar Mohammed dismissed most of applicant Maw Tho's claims, granting only a $2,486.00 chronic pain assessment and interest.
Tho had sought an income replacement benefit of $400.00 per week from January 1, 2023 to date and ongoing, partial amounts for psychological treatment, the chronic pain assessment, an award under s. 10 of Reg. 664, and costs. The adjudicator found she had not met her onus to establish entitlement to the IRB under section 5(1) of the Schedule, noting her submissions did not directly address entitlement or quantum.
A central finding for claims professionals concerned how a clinic billed for treatment time. The plan had been approved in full for one hour of psychological treatment per session, but Allstate's adjuster learned the clinic only provided 45 minutes of treatment per session. The remaining fifteen minutes were used for set-up, note taking and inter-professional dialogue. The applicant argued the insurer was required to pay the full invoices under section 38(11) of the Schedule because Allstate had not denied within 10 business days under section 38(8). The adjudicator disagreed, finding the shall pay provision does not require an insurer to pay for incurred expenses that are not in keeping with the underlying plan.
The decision noted Allstate had separately approved $448.83 for assessment, $149.61 for planning service, $299.22 for documentation support activity, and $200.00 for form completion - meaning preparatory services were already funded outside treatment sessions.
On the chronic pain assessment proposed by Dr. Goldstein, the adjudicator found there were grounds to suggest an investigation was warranted, citing clinical notes documenting persistent pain symptoms and earlier accident-related diagnoses including Chronic Pain and Chronic Lumbar Spine Musculoligamentous Pain. The adjudicator noted neither a diagnosis nor satisfaction of the AMA Guides criteria is required in advance of an assessment intended to address diagnosis.
The tribunal also addressed a motion to admit a late addendum report by Dr. Goldstein dated July 9, 2025, which sought to add analysis of six chronic pain criteria and a diagnosis of Chronic Pain Syndrome. The adjudicator admitted the report but assigned it little weight, finding the evidence did not support the explanation that the analysis and diagnosis were omitted from the original report due to formatting or typographical errors.
Allstate also defeated the section 10 award claim. The adjudicator found the insurer's denial referenced the six chronic pain criteria and indicated an insurer examination was required, and the conduct did not rise to behaviour described as "excessive, imprudent, stubborn, inflexible, unyielding or immoderate." Costs were also denied because the applicant had not engaged with the Rule 19 factors governing costs orders.
