An Ontario tribunal told Co-operators to pay chiropractic benefits after a flawed denial letter, even as the insurer prevailed on its Minor Injury Guideline defense.
The License Appeal Tribunal released its decision in Vallejos v Co-operators General Insurance Company, 2026 CanLII 45590 (ON LAT) on May 13, 2026. Adjudicator Bernard Trottier handled the matter in writing.
The dispute followed a motor vehicle accident on November 20, 2022. The applicant, Margie Vallejos, sought statutory accident benefits. Her chiropractor, Dr. Nelantine Jesuthasa, submitted an OCF-18 for $3,866.90 in chiropractic services on December 1, 2022.
On December 6, 2022, Co-operators emailed the applicant saying it had not received a completed OCF-1 and could not consider the treatment plan. The OCF-1 was submitted the next day. Co-operators issued a substantive denial on June 12, 2023, citing the Minor Injury Guideline. The applicant filed her LAT application on January 20, 2025.
Co-operators argued its December 6, 2022 email started the two-year limitation clock and that the application was therefore out of time. The Tribunal disagreed. Trottier found the December 6 correspondence did not tell the applicant she had a right to dispute the denial and did not mention the two-year limitation period. Applying Smith v. Co-operators General Insurance Co., he ruled the notice was deficient, the clock started on June 12, 2023, and the application was timely.
That finding had financial consequences. Section 38(8) of the Schedule requires insurers to provide medical and other reasons for a denial within 10 business days of receiving an OCF-18. Section 38(11) prevents an insurer that misses that window from later arguing the MIG applies, and obligates payment for goods and services covering the gap period. Trottier found the December 6 letter non-compliant with s. 38(8) and ordered Co-operators to pay the chiropractic services incurred from December 22, 2022 to June 12, 2023, with interest.
On the merits, the insurer fared better. The applicant sought removal from the MIG based on psychological impairments and chronic pain. The Tribunal gave little weight to a psychological assessment by Cody Eriksen, psychotherapist, citing discrepancies with the applicant's medical records. Family physician Dr. Thomas Van's records made no mention of the accident between an initial visit on November 30, 2022 and a visit on November 14, 2024, when the applicant raised her insurer's request for a psychological assessment. Trottier also found no formal chronic pain diagnosis and no functional impairment evidence meeting the criteria in the American Medical Association's Guides.
The applicant's remaining OCF-18s - $1,553.60 for further chiropractic treatment, $2,200 for a psychological assessment, $2,200 for a chronic pain assessment, and $2,460.01 for an attendant care needs assessment - were denied as not reasonable and necessary.
Trottier also refused the applicant's request for a s. 10 award, finding Co-operators' conduct did not meet the threshold of being "excessive, imprudent, stubborn, inflexible, unyielding and immoderate."
