An auto insurer's denial of massage therapy and case management benefits survived reconsideration after a claimant failed to prove they were reasonable and necessary.
The Ontario Licence Appeal Tribunal released its reconsideration decision on July 3, 2026, upholding an earlier ruling that dismissed a claimant's dispute over accident benefits. The message for insurers and claims professionals is direct: the burden sits with the claimant to build the case, and adjudicators are not required to fill evidentiary gaps.
The claimant had sought a treatment plan for massage therapy and challenged partially denied treatment plans for case management services, along with interest. In its March 10, 2026 decision, the Tribunal found she was not entitled to any of it and dismissed the application. On March 30, 2026, she asked the Tribunal to reconsider.
Her core argument was that the adjudicator erred by deciding the case without reviewing the OCF-18 treatment plans she had filed with her original application on September 5, 2024. She said the plans were in the Tribunal's case management records, that any failure to resubmit them was inadvertent, and that the adjudicator should have reviewed the full record or asked her to refile.
The Vice-Chair rejected that reasoning. The key finding was that the original dismissal did not rest on the missing OCF-18s. Instead, the adjudicator had weighed the medical evidence and the claimant's submissions and concluded she had not met her onus.
On the massage therapy claim, the adjudicator relied on a kinesiologist's progress report showing the claimant was benefiting from active treatment - increased activity tolerance, strength and endurance, and stabilized mood and energy, to the point she was taking long bike rides and walks with friends. That active therapy was a different treatment modality than the massage therapy being sought, and it aligned with a physiatrist's opinion. The claimant's submissions also did not address the cost breakdown, the duration of treatment, or who recommended it and why.
The case management services claim failed for similar reasons. The claimant pointed to totals of $3,695 and $5,596.40, of which $2,712.52 and $919.52 respectively had been partially approved, and argued that the insurer's prior approval of the case manager's rate justified the disputed amounts. The adjudicator was not persuaded, finding the earlier approvals insufficient and the case manager's report unhelpful because it did not break down the services or explain why longer or additional sessions were needed.
The claimant also argued a breach of procedural fairness. The Vice-Chair disagreed, holding that because the denial turned on the merits rather than a technicality, the adjudicator was not obliged to search the Tribunal's records or request the missing documents. The Tribunal stressed that reconsideration "is not an opportunity for a party to re-litigate its position."
The reconsideration was dismissed on both grounds. For insurers, the decision reinforces a familiar point at the claims stage: a denial built on the reasonable-and-necessary test holds up when the claimant does not substantiate cost, duration and clinical rationale - and reconsideration remains a high bar.
