A claimant seeking catastrophic impairment benefits fell four percentage points short of the threshold, an Ontario tribunal has ruled.

The claimant was hurt in a car accident on September 30, 2020, and applied for accident benefits from Certas Home and Auto Insurance Company, seeking recognition as catastrophically impaired under Criterion 7 of the Statutory Accident Benefits Schedule. The designation matters: it blends physical injuries with mental or behavioural impairments into one combined score, and that score has to reach 55% before a tribunal will call someone catastrophically impaired.

What followed was a genuine battle of the experts. The claimant's neurologist, orthopaedic surgeon and psychiatrist put his combined score at exactly 55%, just enough to clear the bar. Certas's own panel of assessors landed at 30%, less than half of what the threshold demands. It fell to the Licence Appeal Tribunal to sort out who had it right.

Adjudicator Nadia Mauro didn't just pick a side - she worked through the dispute item by item. On mental status, she sided with the claimant's neurologist, accepting a 14% rating for the cognitive and behavioural symptoms he had reported since the crash. She also accepted 5% for sleep problems and 10% for cervicogenic headaches, headaches that start in the neck and spread forward into the head, distinct from ordinary tension headaches, which she threw out for lacking any real explanation.

Not everything went the claimant's way. Mauro found no support for a smell-related impairment, faulting his assessor for a virtual exam that never explained how sense of smell can even be tested over video.

Down at the lower back, the dispute got tougher to referee. The claimant's orthopaedic surgeon pointed to an MRI showing nerve root involvement and gave it a 10% rating; Certas's surgeon read the same scan as milder, at 5%. Mauro went with the higher number, finding the MRI evidence of radiculopathy - nerve root compression that can cause pain or numbness running down the leg - was not seriously disputed by either side.

Tally it up and the physical injuries alone came to 46%, using a formula that blends categories together rather than simply adding them. Both sides' psychiatrists had already agreed on 10% for behavioural impairment. Add that in, and the total landed at 51%. Four points short.

Mauro dismissed the application on September 15, 2026.

For claims teams, the case is a reminder that catastrophic impairment claims are won or lost on the individual numbers, not on whichever side's bottom-line figure sounds most persuasive.