Certas Home and Auto Insurance Company defeated all disputed accident benefit claims from an injured cyclist at Ontario's Licence Appeal Tribunal.
The applicant was participating in a group bike ride on August 10, 2022, when she veered off a two-lane road to avoid an oncoming vehicle she described as driving erratically. Travelling downhill at approximately 50 km/hr, her bike contacted the gravel shoulder, causing her to fall. She sustained multiple fractures, facial lacerations, and a degloving injury to her right leg.
Because no vehicle made direct contact, the insurer questioned whether the incident qualified as an accident under the Statutory Accident Benefits Schedule. A prior tribunal decision dated October 10, 2024, confirmed it did. The remaining disputes went to a hearing held April 29, 30, and May 1, 2026, before Adjudicator Mary Henein Thorn.
The applicant sought attendant care benefits of $10,487.34 per month based on a Form 1 assessment. The Schedule caps attendant care at $3,000 per month for individuals who are not catastrophically impaired. The adjudicator found no statutory basis to exceed that limit.
Central to the dispute was whether the attendant care should be deemed incurred under section 3(8) of the Schedule. The applicant argued the insurer never advised her of her entitlement, so she did not hire a professional caregiver. Certas pointed to a letter it sent on September 22, 2022, outlining the benefits available to her, explaining how to apply, and including contact information. The adjudicator found the letter "clear, user friendly, precise, with a friendly tone" and concluded the insurer met its obligation to inform the applicant of her possible entitlement.
The applicant's husband served as her primary caregiver. He testified he held an executive position that allowed him to take paid time off. The adjudicator found no evidence of economic loss to any caregiver - a requirement under section 3(7)(e) of the Schedule for expenses to be considered incurred.
Disputed portions of a psychological treatment plan also failed. The applicant's psychologist proposed 1.5-hour sessions at a total cost of $4,927.21, of which Certas approved $2,545.85. A section 44 assessor disagreed with the extended session length, finding the applicant's psychological impairments were not severe enough to warrant it. The adjudicator agreed, noting the applicant continued to drive, cycle, travel, and maintain her executive position. The psychologist had found the applicant fell short of meeting DSM-5 criteria for post-traumatic stress disorder.
An occupational therapy plan totalling $5,886.00 was partially approved at $4,688.75. The applicant made no submissions supporting the denied portions. A previously disputed physiotherapy claim of $199.50 was found to have already been paid directly to the treatment provider.
The tribunal denied a request for a special award under section 10 of Regulation 664, finding no benefits were payable. A request for $1,500 in costs was dismissed after the adjudicator found no unreasonable conduct by the insurer. The application was dismissed in its entirety on July 23, 2026.
