Aviva defeated an attendant care claim after the applicant waited two years to submit his treatment form and incurred no expenses.
The Ontario Licence Appeal Tribunal dismissed the application in a decision released July 13, 2026, ruling that the claimant was not entitled to attendant care benefits, a special award, or interest.
The dispute arose from an automobile accident on October 27, 2022. The applicant sought benefits under Ontario's Statutory Accident Benefits Schedule, but Aviva Insurance Company of Canada denied them. He then applied to the Tribunal, claiming attendant care benefits of $643.25 per month from November 24, 2022, to date and ongoing.
Under section 19(1)(a) of the Schedule, a claimant must prove that attendant care expenses are reasonable and necessary and that they were incurred as a result of the accident. The onus sits with the applicant.
The claim rested on a Form 1 dated December 5, 2022, prepared by an occupational therapist. It recommended 315 minutes a week to help prepare, serve and feed meals, and another 140 minutes a week for bathroom and bedroom hygiene and to ensure his comfort and safety.
Timing proved decisive. The applicant did not submit the Form 1 to Aviva until December 10, 2024 - two years after it was completed. Adjudicator John Mazzilli read that delay as evidence the benefits were not needed when the form was prepared. Section 42(5) also bars an insurer from paying attendant care expenses incurred before a Form 1 is submitted.
The applicant leaned on two medical reports - a chronic pain assessment and a psychological report - to argue his impairments made the benefits reasonable and necessary. But neither assessor offered an opinion on his entitlement to attendant care; both were commissioned to address whether he should be removed from the minor injury guideline.
Aviva countered with three section 44 assessments: an in-home occupational therapy report, a physician's report, and a psychological paper review. The insurer had approved the Form 1 for five months on the basis that the applicant would be reimbursed if he incurred the expense, then formally denied the benefit on April 4, 2025 after its assessors found him independent in the tasks claimed.
Mazzilli placed greater weight on Aviva's assessments, finding them more current and commissioned specifically to address the reasonableness and necessity of attendant care. He accepted that the applicant could manage his personal care independently at pre-accident levels, with sufficient range of motion, strength and tolerance. He also noted the applicant had a five-month window to access the approved benefits and did not, and that he provided no proof of incurring any expenses. The requested benefits, he concluded, were "not reasonable, necessary nor incurred."
The special award claim fell with the benefit. Under section 10 of Regulation 664, the Tribunal may order up to 50 per cent of benefits payable where an insurer unreasonably withholds or delays payment. Because Aviva had not done so, no award was owed. With no benefits payable, interest did not arise either.
The decision was heard by way of written submissions.
