An Ontario tribunal ordered Aviva General Insurance to pay for three medical assessments, then backed its refusal to pay for three treatment plans.

The claimant was hurt in a car crash in July 2021 and turned to Ontario's Licence Appeal Tribunal after Aviva denied every plan he put forward, from chiropractic care to a psychological workup. Six plans went into dispute in total, covering everything from hands-on therapy to formal medical workups, and each one turned on its own slice of evidence. Adjudicator Jim Zotalis released his ruling on September 15, 2026, and the outcome landed three plans apiece.

The winning side: a chronic pain assessment worth $2,799.00, a psychological assessment worth $2,714.25, and an orthopaedic assessment worth $2,714.25, each with interest attached. The losing side: chiropractic therapy worth $2,447.93, plus two physiotherapy plans, one worth $1,312.20 (with $479.50 still contested after a partial payout under the Minor Injury Guideline, Ontario's cap on treatment funding for soft-tissue injuries) and another worth $2,940.30.

Here's the pattern behind the split. An assessment only has to clear the door - its job is figuring out whether an injury is real, so the claimant just needed enough of a reason to look closer, not a confirmed diagnosis. A treatment plan is a different animal. By the time a provider is billing for ongoing chiropractic care or physiotherapy, the claimant has to show the treatment is actually working, not just that the injury is real.

That distinction ran the whole case. The assessments cleared on things like a psychological report flagging an adjustment disorder and a knee ultrasound turning up a possible meniscus tear - modest findings, and that was enough, matching the lower bar assessments face. The treatment plans came up short because the claimant had no referral from his family doctor and no records showing his pain was easing or his movement improving.

One more claim fell away entirely. The claimant also wanted a special award, essentially a penalty Ontario's accident benefits rules let a tribunal impose when an insurer drags its feet unreasonably. Zotalis never had to decide whether Aviva's handling qualified, because the claimant raised the idea too late, in his written submissions instead of at the case conference or in his original application, and fairness to Aviva called for earlier notice.

For claims teams, the same file cleared the bar for an assessment and still fell short for a treatment plan built on the same injury.