A well-timed denial letter and thin medical evidence handed Co-operators a clean win, capping an Ontario accident claim and killing it early.
The Licence Appeal Tribunal dismissed the application on June 25, 2026, siding with Co-operators General Insurance Company on both a limitation defence and the claimant's attempt to escape the Minor Injury Guideline (MIG).
The claimant was involved in an automobile accident on November 20, 2022, and sought benefits under the Statutory Accident Benefits Schedule. He disputed the insurer's refusal to fund a $3,808.40 chiropractic treatment plan, a $2,200.00 psychological plan, and two assessments.
Timing decided the chiropractic claim. Under section 56 of the Schedule, an applicant has two years from a proper denial to bring a dispute to the Tribunal. Co-operators issued a denial letter dated December 6, 2022, explaining that it could not consider the expenses because the claimant's OCF-1 application was incomplete. The insurer argued the claimant had until December 6, 2024, to dispute, and that the application, filed 45 days past that limit, was out of time.
The claimant countered that the first clear denial came on March 17, 2023, making his January 20, 2025 filing timely, and that the plan was payable under section 38(11) because it was denied past the 10-business-day window.
Adjudicator John Mazzilli disagreed. He found the December 6, 2022 letter delivered clear and unequivocal reasons and met the notice requirements. Citing appellate authority, he noted that "the limitation period is triggered once proper notice of denial is provided" - regardless of whether the insurer's reasons were correct. Because the disputed plan was never re-submitted after the claimant completed the OCF-1, the December 2022 denial stood, and the claimant was barred. With no submissions filed on the factors governing an extension, Mazzilli declined to extend the deadline.
He also confirmed the insurer met the 10-day requirement under section 38(8), having responded five days after the treatment request.
On the MIG, the claimant sought removal on the basis of chronic pain and psychological injury. The insurer characterized the injuries as a lumbar sprain and strain, noting the claimant missed one day of work and returned to full-time employment as a machine operator. It pointed to an X-ray showing scoliosis and degenerative change that it argued were not accident-related.
The adjudicator found no contemporaneous evidence of chronic pain with a functional impairment. On the psychological claim, he placed little weight on a report diagnosing major depressive disorder, noting that the named psychologist did not conduct the assessment - a psychotherapist under supervised practice did - and that testing scores fell in the minimal range, out of step with the diagnosis.
The claimant remained in the MIG, so the Tribunal did not assess the treatment plans' reasonableness or necessity. With no benefits owing, no interest applied, and the application was dismissed.
