Aviva has defeated a catastrophic impairment claim after Ontario's Licence Appeal Tribunal rejected an expert report that never assessed the claimant.
The decision, released July 7, 2026, ends a statutory accident benefits dispute and offers claims teams a case study in how assessment methodology and missing records can decide a catastrophic file.
The claimant was driving when his vehicle was struck from behind while stopped at a traffic light on September 27, 2016. He did not seek medical attention at the scene. He later reported pain in his right shoulder, right arm and low back, along with headaches and tinnitus, and said his injuries evolved into chronic and disabling conditions. He also claimed the accident had caused serious and enduring psychological impairments that had become catastrophic.
Aviva denied the catastrophic designation, and the claimant applied to the tribunal. To succeed under the relevant criterion, he had to show a class 4, or marked, impairment in three of four areas of mental and behavioural function under the American Medical Association's Guides. A moderate rating in any of the three disputed spheres would sink the claim.
The claimant leaned on a family physician's report that adopted an occupational therapist's ratings of marked impairment in social functioning; concentration, persistence and pace; and adaptation to work or work-like situations. The problem, the Vice-Chair found, was the methodology. The physician had not personally assessed the claimant and relied on ratings from an occupational therapist and a social worker who were not under his supervision. Under the Schedule, only a physician may conduct a catastrophic impairment assessment. An occupational therapist, the tribunal noted, is "not qualified to provide diagnoses or opine on causation."
The reports also failed to establish a pre-accident baseline. The physician's file listed only two pre-accident records, a sleep study and an emergency room consultation for hypertension, which the Vice-Chair called inadequate. Without a picture of the claimant's prior state, there was no way to measure what the accident actually caused.
Aviva's psychiatric assessor, by contrast, personally examined the claimant, reviewed his pre-accident records and assigned his own ratings, finding moderate impairments in all four domains. The Vice-Chair preferred that report, noting the claimant had told the assessor that several impairments, including a longstanding temper, pre-dated the accident.
The absence of contemporaneous evidence proved decisive. The claimant produced no clinical notes from his family physician, no counselling or psychiatric records, and no prescription summary. He had also stopped taking prescribed psychotropic medication and did not appear to have engaged in recommended counselling. That gap, the Vice-Chair found, made it virtually impossible to gauge the level of impairment or corroborate his self-reports.
The tribunal found a moderate impairment in social functioning and, with a moderate rating already in place for activities of daily living, concluded the claimant fell short of three marked impairments. The application was dismissed.
