An Ontario tribunal restored a driver's income replacement benefit over psychiatric injuries - but found he couldn't prove the amount, and cleared his insurer.
The Licence Appeal Tribunal ruled on July 7, 2026 that the claimant, injured in an August 14, 2022 automobile accident, was entitled to a post-104-week income replacement benefit from June 23, 2025 and ongoing. Wawanesa Mutual Insurance Company had paid both pre- and post-104 benefits up to June 22, 2025 before the dispute reached a five-day videoconference hearing in May 2026.
To qualify for a post-104 benefit under the Statutory Accident Benefits Schedule, a claimant must show a complete inability to do any work for which they are reasonably suited by education, training or experience. A limo driver by trade, the claimant returned to work briefly after the accident but said pain limited the neck movement needed for shoulder checks, that he overmedicated, and that anxiety forced him to pull over while carrying passengers.
Wawanesa leaned on a section 44 physiatrist who found the accident-related neck and back injuries had reached maximal recovery, leaving only minor range-of-motion restrictions. That assessor also observed the claimant perceived himself as more disabled than his physical findings suggested, while acknowledging a psychiatric component to his pain.
That psychiatric evidence proved decisive. A section 25 catastrophic-impairment psychiatrist and a section 44 psychiatrist both diagnosed a somatic symptom disorder tied to the accident, and both rated his somatic concerns as moderately severe using the American Medical Association Guides. Adjudicator Harry Adamidis accepted the only medical opinion that linked those mental health disorders to the post-104 test, finding the claimant met the threshold on a balance of probabilities.
Wawanesa's vocational and functional evidence did not hold up. A labour market survey identifying office jobs was set aside for failing to address the claimant's functional limitations. A functional abilities evaluation deemed unreliable for inconsistent effort carried little weight after the kinesiologist testified the poor effort could stem from pain and that he "does not know" about the psychological factors at play.
The victory came with a catch. The claimant sought $400 a week but made no submissions on how that figure was calculated and pointed to no financial records. Without a way to run the numbers, the adjudicator found he was entitled to the benefit but could not fix its amount.
Wawanesa fared better elsewhere. The tribunal denied every disputed treatment plan - covering psychological services, catastrophic assessments, occupational therapy and prescription medication - because the claimant did not show they were reasonable and necessary. It also rejected a special award under section 10 of Regulation 664, which allows up to 50 per cent of benefits payable where an insurer unreasonably withholds or delays payment.
Though Adamidis disagreed with Wawanesa's conclusions on the benefit, he found its adjustment decisions were grounded in evidence and could not be called unreasonable. He likewise declined costs over the insurer's late-filed book of authorities, noting it had compromised by cutting its 59 cases to 12. The claimant was awarded interest on the overdue benefit.
