A May 6, 2026 ruling handed Co-operators a clean win on a missed insurer's exam - and a loss over a paperwork slip the insurer admitted itself.
The Ontario License Appeal Tribunal's decision in Cruz v Co-operators General Insurance Company is the kind of split outcome accident benefits adjusters will want to read closely. It rewards insurers who do the procedural work properly and penalizes those who let a single notice slip through the cracks.
The case started with an October 2, 2022 car accident. Teri-Ann Cruz sought statutory accident benefits and, after a string of denials, took her fight to the tribunal. On the table: occupational therapy treatment plans, a mental health driving assessment, a dietician assessment, and a request for a special award alleging unreasonable conduct by the insurer.
Co-operators' first move worked. The insurer asked Cruz to attend an examination with occupational therapist Tony Jung on July 30, 2024 to review a $6,033.60 occupational therapy plan. Cruz's representative pushed back, calling the insurer's reasons "vague and boilerplate" and accusing Co-operators of being "flagrantly non-compliant" with the Schedule. She did not attend.
Adjudicator Nadia Mauro was not persuaded. She found the notice of examination gave a "particularly detailed account of the applicant's medical record" and met the legal threshold. As she put it, "the applicant may choose to not agree with the reasons provided by the respondent, but that does not unilaterally render the NOE non-compliant." The protection built into the rules, she added, exists "to protect an insured from unreasonable or unnecessary assessments, not to provide a shield for an applicant not to attend." Cruz was barred from pursuing the $6,033.60 claim.
Then came the turn. Co-operators conceded that, "by inadvertence," it had failed to send Explanation of Benefits letters for two other plans - a $4,892.00 mental health driving assessment and a $2,225.00 dietician assessment, both dated January 17, 2025. The insurer argued the deemed approval should still be capped by industry rate guidelines.
Mauro shut that door. Leaning on Kyrylenko v. Aviva Insurance Canada, she ruled that once the notice rules are broken, "it is mandatory that the insurer pay for all goods, services, assessment and examinations described in the treatment plan." Trying to second-guess hourly rates after the fact, she said, would defy the rule itself. And citing Aviva v Suarez, she added it was "no longer open to the respondent to cure the denials."
On a separate $7,073.12 occupational therapy plan dated January 6, 2025, Mauro approved only the core treatment and claim-form documentation lines, trimming travel, mileage, planning, preparation, and progress-report items as not reasonable and necessary. The denial letter itself, she found, complied with the Schedule under the Court of Appeal's reasoning in Varriano v. Allstate.
Cruz's bid for a special award failed. The EOB lapse, Mauro wrote, was "an error in adjusting the file" - not the "excessive, imprudent, stubborn, inflexible, unyielding, or immoderate" conduct the law demands.
The lesson for claims teams is simple. A well-documented exam request will hold up, even under aggressive pushback. A missed EOB will not - and no rate guideline will save the file once that notice goes unsent.
