Aviva scored a clean sweep at Ontario's Licence Appeal Tribunal after a claimant's own words, told to different assessors, contradicted each other at every turn.
The decision in Lam v. Aviva General Insurance Company, released April 13, 2026, saw Adjudicator Kathleen Wells dismiss all four treatment plan disputes brought by Sau-Leung Lam, who was injured in a June 3, 2020 automobile accident. The case turned not on complex policy language, but on something more fundamental - whether the claimant's account of his own condition held up under scrutiny. It did not.
Lam sought outstanding balances on treatment plans for chiropractic, physiotherapy, and psychological services under Ontario's Statutory Accident Benefits Schedule. Aviva had partially approved three of the four plans, denying $320 in transportation costs on two and the full $4,383.90 on a third chiropractic plan. A psychological services plan was approved at $2,900, with the remaining $1,250.56 denied over a disagreement about how much a social worker should be paid per hour.
What stands out here is how the Tribunal used the claimant's inconsistent statements across multiple assessments to undercut his case. During a June 2022 in-home assessment with occupational therapist Raymond Wong, Lam said he was on sick leave. But a year earlier, he told Dr. Gilbert Yee, an orthopaedic surgeon conducting a section 44 examination, that he had returned to work as a part-time property manager after the accident and could continue working - only that the position was no longer available after the onset of the pandemic and the tenants moving out of the building he managed.
The pattern repeated on daily living. Lam told two assessors he could no longer cook or clean. Then, at a June 2024 functional assessment, he informed occupational therapist Laura Youm that he had never performed those duties before the accident either.
The Tribunal leaned heavily on the insurer's examination by Dr. Esmat Dessouki, an orthopaedic surgeon who found functional range of motion in Lam's neck, back, and shoulders, no overt pain behaviours, and no objective evidence of continuing impairments. Lam's own history also showed prior neck and bilateral shoulder pain from a 2017 accident, along with mild degenerative changes on imaging.
Adding to the picture, clinical records from Total Recovery Rehab Centre showed no significant improvement after more than 50 treatments Aviva had already approved. And while Lam told one assessor physiotherapy relieved his neck pain, he told a psychiatrist in March 2023 he had received physiotherapy "to no avail."
The rate dispute on the psychological plan was narrower but telling. The treatment plan billed at $149.61 per hour - the psychologist rate under the Professional Services Guideline - for work done by a social worker. The Guideline sets no rate for social workers, so Aviva offered $100 per hour. Lam never justified the higher rate.
The Tribunal also rejected the argument that Aviva's denial notices failed to meet section 38(8) of the Schedule, finding each Explanation of Benefits clear enough for any person to understand and act on.
The application was dismissed in full. No interest or penalty award was granted.
