Certas Direct Insurance Company beat back most of an Ontario accident-benefits dispute, with an adjudicator citing thin medical evidence and missing records.
The Licence Appeal Tribunal released its decision in Kagoya v. Certas Direct Insurance Company, 2026 CanLII 50991 (ON LAT) on May 25, 2026. The applicant, Farida Kagoya, had been involved in an automobile accident on April 28, 2022, and sought benefits under the Statutory Accident Benefits Schedule.
Four items were in dispute: $1,270.27 for physiotherapy, $1,050.88 for an Attendant Care Assessment, $2,300.00 for a Mental Health/Psychological Assessment, and $2,300.00 for an Orthopaedic Surgery Assessment, all proposed in 2022 treatment plans. Adjudicator Gary Harvey approved only the psychological assessment. The physiotherapy claim, the attendant care assessment, the orthopaedic assessment, and interest were all denied.
The applicant did not seek medical attention until June 20, 2022 - nearly two months after the accident - when she attended Toronto Western Hospital. A CT scan of her brain and an abdominal ultrasound returned normal findings, and she was discharged with instructions to manage symptoms with Tylenol or Advil. Her family physician's clinical notes contained no entries tied to accident-related injuries. The adjudicator noted that an OCF-18 alone, without supporting medical evidence, does not establish that a treatment plan is reasonable and necessary.
Certas relied on a section 44 Independent Physiatry Assessment by Dr. Shariff Dessouki, who concluded the applicant had no objective accident-related musculoskeletal impairments. The applicant argued Dr. Dessouki had not reviewed key exercise and aqua therapy reports, but the adjudicator found those documents were in the appendix of his report and accepted the IE findings.
The applicant had been ordered in the Case Conference Report and Order to produce particulars of collateral benefits and prior or subsequent accident files. She filed no reply submission addressing the gap. The adjudicator accepted Certas's submission that the documents had not been disclosed, and pointed to s. 47(2) of the Schedule, which limits the insurer's obligation where payment is reasonably available under another plan.
On the attendant care assessment, the adjudicator found Certas's initial denial referencing the Minor Injury Guideline was compliant with s. 38(8) because, at that time, the insurer had no medical records from the applicant. Certas had requested clinical notes and records multiple times before receiving them on January 11, 2023.
The applicant did secure one win. On January 13, 2023, Certas removed her from the MIG based on pre-existing psychological issues dating back to 2015, with repeat complaints in 2021 and 2023. Combined with a November 2023 anxiety flare-up that prompted a psychotherapy referral, the adjudicator found grounds to investigate further by way of a psychological assessment.
The orthopaedic assessment failed for similar reasons to physiotherapy - the applicant pointed to no clinical notes supporting accident-related physical impairments, and there was a 21-month gap in chiropractic care. Interest was denied because no benefits were overdue.
