What happened: Ontario's Licence Appeal Tribunal turned down a catastrophically impaired claimant's bid for the rest of 16 treatment plans.
Who's involved: Intact Insurance Company and a claimant hurt in an October 2021 car crash.
What's at stake: Unpaid balances of $199.83 to $4,959.88 per plan, plus interest and a penalty award.
Why it matters: A treatment plan's own recommendation isn't proof the treatment is reasonable or necessary.
Where it stands: Decided September 25, 2026. Intact owes nothing more on the disputed plans.
Intact Insurance Company had already agreed its claimant was catastrophically impaired. It still didn't owe her a cent more on 16 treatment plans.
Intact made that call on September 23, 2024. A catastrophic designation is Ontario's top tier of accident benefits. For crashes on or after June 1, 2016, it raises the combined cap on medical, rehabilitation and attendant care to $1 million, up from $65,000.
But a bigger pot doesn't change who has to prove each bill. On September 25, 2026, Ontario's Licence Appeal Tribunal turned down every disputed balance, refused interest, and found Intact owed no penalty for holding back payment.
The claimant was hurt in a car accident on October 19, 2021. Both sides agreed she had significant psychological impairments. The fight was over her physical injuries and the leftover charges Intact had trimmed.
Intact had already approved a good share. By Insurance Business's tally of the decision's figures, it signed off on about $73,200 of the roughly $104,800 billed across the 16 plans.
The biggest physical item was a wheelchair. The claimant argued the crash fractured her spine and hurt her right hip, which led to a tumour on her right thigh, surgery and then the chair.
The tribunal didn't find that in the records. Her emergency room notes, taken about a week after the crash, flagged eye issues, vomiting and dizziness, but nothing about a spine or hip injury. Hip imaging in July 2023 was normal apart from slight degenerative changes.
Her timeline moved, too.
In February 2024, she told the orthopaedic surgeon who diagnosed her tumour that her hip was struck in the crash. That July, she first told the orthopaedic surgeon examining her for Intact that the pain started right after the accident. Asked again, she said it began in May 2023.
The tribunal noted she never explained the gap.
A chiropractor and a physiotherapist had linked the tumour to the accident in their treatment plans. The tribunal gave that link little weight because it came "without any explanation or supporting documentation."
It sided with the two orthopaedic surgeons instead, finding them better qualified to assess this kind of tumour. The surgeon who diagnosed it never tied it to the crash, and Intact's surgeon found no link. With nothing connecting the wheelchair to the accident, that claim was out.
Most of the other charges were never argued. The claimant made no submissions on report fees, travel costs, planning and preparation fees, progress reports or the fee for filling out the forms. She also didn't produce copies of two of the plans. For one of them, the tribunal said it couldn't even tell what the remaining balance was for.
That matters, because the claimant has to show each treatment is reasonable and necessary. Silence doesn't get her there.
The psychology plans called for 90-minute sessions. The claimant pointed to two earlier tribunal decisions that left session length to the treating psychologist.
The tribunal said those cases had competing expert reports, while this one had only the treatment plans. "Recommending a course of treatment in an OCF-18 is not evidence that the treatment is reasonable or necessary," it wrote.
Hourly rates were the last fight. Ontario's Professional Services Guideline caps what insurers pay for many health services, but it sets no maximum for social workers or psychotherapists. Intact offered $134.17 an hour for one social worker and $89.07 for another social worker and a psychotherapist, based on their qualifications.
The tribunal said the guideline's silence "does not automatically entitle the applicant to the higher hourly rate." She pointed to no extra qualifications that would justify more.
That left the penalty. Ontario's rules let the tribunal add up to 50 per cent of benefits, plus interest, when an insurer unreasonably holds back or delays payment. With nothing owed, nothing was held back.
Trimming an OCF-18 to the guideline rate, or setting a rate where the guideline is silent, held up here because the claimant had to justify the extra, not Intact.
The decision doesn't mention any plan by either side to seek reconsideration or appeal.
