An Ontario tribunal handed Belair Insurance a split decision, denying provider travel time on an in-home assessment while ordering payment for documentation hours behind a detailed report.
Christina Semenya was involved in an automobile accident on July 30, 2022, and sought benefits under the Statutory Accident Benefits Schedule. After Belair Insurance Company Inc. partially denied a treatment plan, she applied to the Licence Appeal Tribunal. The decision in Semenya v Belair Insurance Company Inc., 2026 CanLII 56665 (ON LAT) was released on June 10, 2026, by adjudicator Melanie Malach.
The dispute centred on an OCF-18 dated January 10, 2023, proposed by FunctionAbility Rehabilitation Services Inc. for an in-home occupational therapy examination report totalling $1,679.29. Belair approved $897.75 by correspondence dated January 23, 2023, leaving $781.54 in dispute across three line items.
The first was $100.25 for completion of the OCF-18 form. Although $200.00 is the maximum fee under the Professional Services Guideline, Malach found it is not automatically payable, and the onus sat with the applicant. Belair had approved one hour, then asked the provider to explain why more time was needed. The provider's correspondence did not address completion time. Malach found the applicant had not proven entitlement to the balance.
The second item was $82.79 for provider travel time. Belair relied on the transportation expense rules in the Schedule, under which an insurer is not liable for transportation expenses other than authorized ones. Malach agreed the approved in-home assessment required the provider to travel to the applicant's home, but found that travel was a component of the assessment and part of the regular business practice of performing it. Because no reasonable explanation showed the travel exceeded that practice, she found it was not an authorized transportation expense and denied the amount. She noted she was not bound by the other Tribunal decisions both sides cited.
Belair lost on the third item. The provider had claimed nine hours of documentation - one hour for a Form 1 and eight for the report - of which Belair approved three. Reviewing the work product, Malach found the assessment report ran 29 pages and was extremely detailed and thorough. She found it would have taken more than the approved three hours and that eight hours was reasonable, while the one-hour Form 1 estimate was also reasonable given the calculations involved. The applicant was awarded $598.50, plus interest under the Schedule.
Semenya also sought a special award under s. 10 of Reg. 664, which allows up to 50 percent of benefits payable where an insurer unreasonably withheld or delayed payment. She pointed to delayed file production and adjustment she described as stubborn and protracted. Malach was not persuaded. On the disputed plan, she found Belair had reasonable grounds to partially approve it, observing that insurers are entitled to make errors and are not held to a standard of perfection. Noting Belair had paid $62,988.26 in benefits, she found no conduct rising to the threshold and declined the award.
The result is a reminder that line-by-line adjusting can survive scrutiny - but only where each denial is explained and each approval is matched to the work actually delivered.
