What happened: An Ontario tribunal denied a catastrophic impairment claim after finding the claimant's expert ratings lacked objective medical evidence.
Who's involved: Certas Home and Auto Insurance Company and a claimant seeking accident benefits after a 2022 car accident.
What's at stake: Catastrophic designation - which would unlock expanded benefits - plus $400 per week in income replacement and over $26,000 in disputed treatment costs.
Why it matters: The decision shows that self-reported symptoms alone will not sustain impairment ratings at tribunal, even when an expert assigns them a number.
Where it stands: Decided by the Ontario Licence Appeal Tribunal on October 5, 2026.
One expert rated her at 58 per cent whole-person impairment. The insurer's expert said 13 per cent. The tribunal landed at 38 - and denied the claim.
An Ontario auto accident claimant's push for catastrophic impairment status fell apart at the Licence Appeal Tribunal after the adjudicator found that much of her expert's assessment was built on what she told him, not on what her medical records showed. The decision, released October 5, 2026, cut her best-case physical impairment score to 38 per cent - well short of the 55 per cent threshold needed for catastrophic designation under Ontario's statutory accident benefits regime.
The case started with a May 2022 car accident. The claimant sought benefits from Certas Home and Auto Insurance Company, including catastrophic status, income replacement and funding for a string of treatment plans submitted through her physiotherapy clinic. Certas denied the catastrophic designation and fought most of the treatment claims.
The gap between the two sides' experts was remarkable. The claimant's assessor, a general practitioner, rated her across more than a dozen impairment categories, arriving at 58 per cent under the physical criterion and 71 per cent when mental health scores were added. The insurer's orthopaedic surgeon put the same numbers at 13 per cent and 26 per cent.
The tribunal's findings tracked far more closely with the insurer's side. Both experts agreed on the claimant's neck, lower back and left shoulder injuries - roughly five per cent each. Where they parted company was on a long list of additional impairments the claimant's expert had scored: mid-back, right shoulder, hips, right knee, ulnar nerve, cognitive function, tinnitus, vision and jaw.
In each case, the tribunal found the same problem. The ratings rested on what the claimant reported during her assessment rather than on objective test results or consistent medical records.
Her family doctor had seen her five times in the six weeks after the accident. Those medical notes - which the tribunal gave significant weight as records made at the time - said nothing about pain in the mid-back, hips, knee or right shoulder. The claimant's expert did not examine her until September 2024, more than two years later.
Some of the specific gaps were hard to miss. The claimant's expert assigned a five per cent rating for jaw pain based on her report that she had stopped eating steak, apples and carrots. The tribunal was not persuaded. She had worn dentures since before the accident, and her expert admitted he never asked whether her chewing difficulties predated the crash.
The ulnar nerve rating told its own story. The expert scored it at 12 per cent - but the claimant later had surgery that cleared up her symptoms for months. He acknowledged his rating applied only as of his September 2024 assessment. A later orthopaedic examination found no ulnar symptoms at all.
For cognitive impairment, the only test on record - a standard screening - came back normal. No detailed neuropsychological testing was ever done. Zero per cent.
Tinnitus and vision ratings fared no better. The expert conceded he had no hearing or vision measurements to work with. The claimant said she had taken a hearing test, but the results were never produced. A diagnostic imaging report was also excluded from evidence after the claimant's side failed to disclose it before the hearing, leaving the insurer no opportunity to have its own experts review it.
On the mental health side, the tribunal preferred the insurer's psychiatrist, who scored the claimant at 15 per cent, over her own psychiatrist at 30 per cent. The higher score lacked individual breakdowns that would have allowed the tribunal to test it against the rest of the evidence. The claimant's own testimony - that she kept close relationships with her parents, brother and long-term partner, could drive on the highway, and was working part-time - pointed toward the lower number.
Even on the most generous reading, the tribunal found the claimant reached 38 per cent for physical impairments and 47 per cent when mental health was added. Neither cleared the 55 per cent bar.
The income replacement fight turned on the claimant's return to work at her father's printing business. Certas had denied her $400-per-week benefit. The tribunal granted it for a narrow window - January 30 to May 11, 2024 - but not beyond.
After 104 weeks, the legal test tightens: the claimant must show a complete inability to do any job she is reasonably suited for, not just her old one. She argued her return to work was only possible because her father gave her extraordinary accommodations - setting her own hours, skipping the heavy lifting, sometimes being paid for shifts she left early.
The payroll told a different story. Between July 2025 and February 2026, she averaged 27.7 hours a week. Her vocational assessor and orthopaedic surgeon had both based their opinions on her report that she was working about 15 hours. Her 2025 earnings of $20,796 were not far below her pre-accident income of $28,935.
The tribunal also approved three treatment items the insurer had denied: a TENS unit and cane ($699.99), a chronic pain assessment ($2,426) and a block of physiotherapy ($4,422.48). The chronic pain assessment succeeded because clinic notes from just before the plan was submitted documented daily pain and regular medication use - and a specialist subsequently confirmed the diagnosis. Several other physiotherapy and psychology plans were denied because the only evidence supporting them was the plans themselves.
For claims professionals handling catastrophic impairment files in Ontario, the takeaway is direct: an expert's number is only as strong as the objective evidence underneath it, and payroll records can quietly dismantle a disability claim built on what the claimant says rather than what the records show.
The decision was issued by the Ontario Licence Appeal Tribunal on October 5, 2026. It is a final decision on the merits, subject to any available review or appeal.
