Her psychological report had a problem the tribunal couldn't overlook.
The Licence Appeal Tribunal has dismissed an applicant's bid to escape the $3,500 Minor Injury Guideline (MIG) cap, finding that a psychological assessment relied on to support her claim actually described a different collision than the one at issue.
The applicant was involved in two 2021 automobile accidents: one on October 10, in a vehicle insured by Co-operators General Insurance Company, and a second on November 3, in a rental vehicle Co-operators did not insure. Her application to the tribunal identified only the October accident. She disputed Co-operators' denial of two treatment plans: $3,376.51 for physiotherapy, proposed in an OCF-18 dated May 18, 2022, and $2,486.00 for a psychological assessment, proposed in an OCF-18 dated February 21, 2023.
On the physical injuries, the tribunal found no basis to remove the applicant from the MIG. She sought medical attention at a hospital the day after the October accident, was discharged with a diagnosis of musculoskeletal sprains, and her family physician's notes made no mention of the October accident across several 2022 visits. The tribunal gave little weight to an OCF-18 and an OCF-3 submitted as evidence of physical impairment, consistent with its prior finding that OCF-18s are not reliable medical evidence.
On the psychological claim, the applicant showed a pre-existing post-partum depression diagnosis from December 2019, satisfying the first part of the two-part MIG-removal test under section 18(2) of the Statutory Accident Benefits Schedule. She failed the second part. The psychological assessment she relied on, dated March 11, 2024, described the accident as occurring on Highway 401 with her rental vehicle struck on the side and its window breaking - details matching the November accident, not the October accident the report claimed to assess. The tribunal also found the assessors had not reviewed her medical file and had not addressed validity testing in the psychometric testing performed. The report was found "of limited evidentiary value and should be given little weight."
A psychiatrist who saw the applicant in March 2023, after an overdose of diabetes medication the prior month, gave a probable diagnosis of adjustment disorder secondary to on-line harassment and extorsion, with no reference to the October accident. Records from her family physician and from a hospital she visited ten times between May 2022 and May 2024 likewise made no mention of it. On balance, the tribunal found her psychological condition resulted from factors unrelated to the accident.
The applicant argued that because Co-operators never arranged an insurer's examination into her psychological state, the assessment supporting her claim stood uncontroverted. The tribunal disagreed, noting section 44(1) of the Schedule permits, but does not require, an insurer's examination, and does not obligate an insurer to arrange one before denying an OCF-18.
With her injuries found minor and the MIG limit exhausted, the tribunal did not need to assess whether the disputed plans were reasonable and necessary. No benefits were payable, so no interest was owed. The application was dismissed on July 29, 2026.
For claims professionals, the decision underscores the value of checking assessment reports for internal consistency - whether the accident details match the claim in dispute - and confirms a denial can stand without an insurer's examination on file.
