A claimant recovered only a fraction of disputed benefits after Ontario's Licence Appeal Tribunal clarified when insurers may suspend income replacement payments.
The dispute stemmed from a July 13, 2023 automobile accident. The claimant sought statutory accident benefits from Definity Insurance Company, which denied the claims, prompting an application to the Licence Appeal Tribunal's Automobile Accident Benefits Service. Adjudicator Nadia Mauro decided the matter on written submissions, releasing her decision on June 29, 2026.
At the centre of the ruling was the Minor Injury Guideline, which caps medical and rehabilitation benefits at $3,500 for predominantly minor injuries. The claimant argued that chronic pain and a psychological impairment should lift him out of that cap. The adjudicator disagreed.
Mauro preferred the insurer's section 44 assessment reports over the claimant's own assessments. The insurer's physiatrist and psychologist had relied on contemporaneous clinical notes and records, she found, while the claimant's assessors leaned largely on self-reported complaints without corroborating evidence. A single reference to the accident in clinical notes over a 19-month span, she noted, could not establish accident-related chronic pain with functional impairment. The claimant remained within the Minor Injury Guideline, and the disputed treatment plans were not payable.
The income replacement benefit dispute delivered the claimant's lone success. Definity had suspended the $58.92 weekly benefit as of July 14, 2024, citing the claimant's failure to provide financial documents it had requested under section 33 of the Schedule. Section 33(6) relieves an insurer of liability for any period during which the insured fails to comply with such a request.
Mauro found the requested financial documentation was reasonably required to calculate the benefit - up to a point. Once Definity received its section 44 examination results on May 30, 2025 and had enough information to decide entitlement, the outstanding financial documents were no longer reasonably required. From that date, she held, section 33(6) could no longer justify the suspension.
The adjudicator drew on the Tribunal's reasoning in a 2025 Co-Operators decision, where earlier information requests ceased to be reasonably required once the insurer made its entitlement decision. She awarded the claimant income replacement benefits from May 30, 2025 to October 7, 2025, plus interest, while denying the benefit for the earlier period from July 15, 2024 to May 29, 2025.
The claimant also sought a special award under section 10 of Regulation 664, which lets the Tribunal order up to 50 per cent of benefits payable where an insurer unreasonably withholds or delays payment. Mauro declined. Although Definity had withheld benefits, she characterized its conduct as "a wrong adjusting decision" rather than conduct excessive or immoderate enough to justify a penalty.
For claims professionals, the decision marks a practical boundary. An insurer may rely on section 33 to pause benefits while genuinely gathering information to assess entitlement. But once it holds the evidence needed to decide, continued reliance on outstanding document requests to suspend payment invites a different outcome.
