Aviva has defeated an Ontario accident benefits claim after a tribunal found the claimant tried to sidestep the minor injury cap without medical evidence.
The Licence Appeal Tribunal, in a decision released July 9, 2026, dismissed a bid for statutory accident benefits following an April 22, 2024 automobile accident. Aviva Insurance Company of Canada had denied the benefits and classified the injuries as predominantly minor, holding treatment to the $3,500 Minor Injury Guideline limit.
The applicant disputed three items - $4,580.08 for chiropractic services proposed in a treatment plan, $2,200.00 for a psychological assessment, and $70.00 in doctor's fees claimed on an OCF-6. To reach any of them, the applicant needed to be removed from the guideline.
Rather than lead medical evidence, the applicant built the case around the insurer's paperwork. The position was that once a claimant overcomes the reasons set out in a section 54 denial notice, the disputed benefits become payable and the claimant is removed from the guideline. The applicant also argued Aviva had failed to comply with section 38(8) of the Schedule.
Adjudicator Amar Mohammed was not persuaded. The applicant offered no authority for that reading of the removal test and had not even alleged the insurer failed to meet section 54's requirements. Section 38(8), he found, was relevant but did not open a path to permanent removal from the guideline.
The real problem was evidentiary. The applicant sought substantive relief - removal from the guideline and a finding that the treatment was reasonable and necessary - but led no substantive arguments or medical evidence to support it. Because the onus sits with the applicant, the strength or weakness of the insurer's denial notices could not carry the claim.
For claims handlers, the more instructive part of the decision concerns the denial notices themselves. Section 38(8) requires an insurer to give its medical and other reasons for denying a plan within 10 business days. Reviewing Aviva's June 28 and September 6, 2024 denials, the adjudicator found both compliant. Adjusters, he noted, are not expected to produce something resembling a medical opinion, nor to be "held to a standard of perfection" - and the insurer was not qualified to complete a medical analysis in any event.
The denials gave a principled rationale grounded in the file, citing the guideline, requesting evidence to support removal and, for the chiropractic plan, explaining why it was considered excessive. Read together, the adjudicator found, they gave enough for an unsophisticated person to understand the decision and choose whether to dispute it.
The remaining claims fell with the main finding. With no benefits overdue, no interest was payable. The applicant's request for a special award under section 10 of Regulation 664 - which can reach 50 per cent of benefits payable where an insurer unreasonably withholds or delays payment - also failed, as the tribunal found nothing had been unreasonably withheld or delayed.
The application was dismissed.
