An Ontario tribunal has sided with Aviva, rejecting a catastrophic impairment claim after finding the applicant's medical assessors inflated her whole person impairment scores.
In Dobrovolskaia v Aviva General Insurance Company, 2026 CanLII 56629 (ON LAT), the Licence Appeal Tribunal dismissed Evguenia Dobrovolskaia's bid for catastrophic impairment status following a September 27, 2016 automobile accident. Aviva had denied the benefits, and Dobrovolskaia applied to the tribunal seeking a catastrophic finding under Criteria 6, 7, and 8 of the Statutory Accident Benefits Schedule.
The gap between the two sides was wide. The applicant's assessors at Galit Liffshiz and Associates rated her physical whole person impairment at 59 percent. Aviva's assessors put it at 5 percent. Criterion 6 requires 55 percent or more physical whole person impairment under the American Medical Association's Guides.
Adjudicator Nadia Mauro worked through each disputed body region and landed in the middle, but well short of the threshold. She accepted a 15 percent spine rating, an 11 percent upper extremity rating, a 7 percent lower extremity rating, and a 7 percent sleep and fatigue rating, while assigning zero for headaches, jaw, tinnitus, and neurocognitive impairment. Her Criterion 6 total came to 36 percent.
Much of the decision turned on how the applicant's experts built their numbers. Mauro found that the applicant's rating physician used the highest figure in a series of ranges without explanation, which skewed the overall result. She was also unpersuaded by ratings tied to conditional or self-limiting language. On the neurocognitive score, the assessor had written that he did not "evaluate cognition in detail." The adjudicator gave that rating little weight.
Under Criterion 7, which combines physical and psychological impairment, the applicant claimed a combined 75 percent. Aviva's side reached 15 percent. Mauro preferred the respondent's psychological assessor, who administered the required psychometric testing under the AMA Guides and arrived at a 10 percent mental and behavioural rating. Combined with the 36 percent physical rating, she reached 42 percent - again short of 55 percent.
The Criterion 8 analysis carried a pointed message for claims handlers. That criterion looks at four domains of functioning and requires marked impairment in three, or one extreme impairment. The adjudicator found only moderate impairment across all four. She gave less weight to the occupational therapist's domain ratings, noting that an occupational therapist cannot diagnose mental or behavioural disorders, and she preferred the respondent's psychiatry assessment.
Evidence of the applicant's real-world functioning did much of the work. Mauro noted the applicant lived alone, managed self-care and household tasks, ran a travel agency with employees, managed a rental property and its complaints, acted as a realtor in buying and selling her own property, and travelled internationally after the accident. She also found many of the applicant's reported limitations stemmed from physical pain rather than a mental or behavioural disorder.
Mauro concluded the applicant had not met her onus under any of the three criteria and dismissed the application. The decision was released June 11, 2026.
For accident benefits insurers, the ruling reinforces a familiar lesson. Ratings anchored in the AMA Guides methodology, paired with evidence of what a claimant actually does day to day, continue to defeat overstated catastrophic claims.
