An Ontario tribunal has overturned Certas Home and Auto Insurance Company's denial of catastrophic-impairment benefits, ruling the insurer's own psychiatric assessment unreliable.
The Licence Appeal Tribunal released it on June 22, 2026, after a videoconference hearing held April 20 to 24, 2026. For claims professionals handling accident benefits files, the decision is a pointed reminder that the quality of a section 44 assessment can decide the outcome.
The dispute arose from an automobile accident on May 17, 2017. The applicant sought statutory accident benefits under the Statutory Accident Benefits Schedule, was denied by Certas, and applied to the Tribunal. At the start of the hearing she withdrew every issue except one - whether she had sustained a catastrophic impairment as defined by the Schedule.
The claim proceeded under criterion 8, which measures mental and behavioural impairment using the American Medical Association's Guides to the Evaluation of Permanent Impairment. Because the accident occurred in 2017, the test required marked (class 4) impairment in at least three of four spheres of functioning - activities of daily living, social functioning, concentration persistence and pace, and adaptation - or a single extreme (class 5) impairment.
The applicant relied on a section 25 multidisciplinary assessment led by a psychiatrist who found marked impairment in all four spheres and tied her diagnoses to the accident. Certas relied on a section 44 assessment by its own psychiatrist, who found only mild impairment in three spheres, no impairment in the fourth, and concluded the applicant was functioning at her pre-accident level.
The adjudicator gave the applicant's psychiatric report very high weight, pointing to its extensive file review, psychometric testing, and corroborating occupational therapy and collateral interviews. The insurer's report fared far worse. The adjudicator found it offered limited analysis, failed to incorporate the observations of the insurer's own occupational therapist, and cited only a handful of documents despite listing extensive materials as reviewed.
He also questioned whether the insurer's psychiatrist understood the legal test, noting she focused on diagnosis rather than function and repeatedly measured the applicant against a clinical population she described as far worse off. Taken together, the adjudicator found, the insurer psychiatrist's "reliability is suspect."
Working through each sphere, the adjudicator found marked, class 4 impairment in all four. He pointed to the applicant's withdrawal from her community and social life, her errors and inefficiency on standardized cognitive testing, and evidence of deterioration under minor stress, including suicidal ideation reported more than eight years after the accident.
On a balance of probabilities, the adjudicator concluded the applicant had suffered a catastrophic impairment under criterion 8. The decision was released June 22, 2026.
