An Ontario tribunal rejected a catastrophic impairment claim against Definity Insurance Company but ordered the insurer to reinstate income replacement benefits.
The applicant was injured in an automobile accident on October 3, 2018, and sought statutory accident benefits from Definity Insurance Company. The insurer denied the benefits, and the dispute went to the Licence Appeal Tribunal for a hearing held by videoconference from June 1 to June 8, 2026. The case was complicated by a pre-existing chronic pain condition the applicant had lived with for years before the accident, and he later underwent two spinal surgeries and two shoulder surgeries.
The tribunal first found the applicant was barred from disputing $12,430.00 in unpaid catastrophic assessment costs. He had submitted a treatment plan for $25,990.00 in February 2022, and Definity approved $13,560.00 of it the following month. He did not file his dispute until July 7, 2025, more than two years after the partial denial, so section 56 of the Statutory Accident Benefits Schedule barred the claim.
Adjudicator Lisa Holland then turned to whether the applicant met the threshold for a catastrophic impairment under Criterion 7 or Criterion 8 of the Schedule. Competing medical assessors produced sharply different whole person impairment ratings: the applicant's team calculated a combined 60 percent, while Definity's assessors calculated 20 percent. Holland rejected several of the applicant's ratings, including scores for urinary and sexual dysfunction, headaches and vertigo, as unsupported by the medical record, and settled on a combined rating of 23 percent, short of the 55 percent needed to qualify.
His functioning in areas such as shopping, banking, medical appointments and family relationships also fell short of the marked impairment standard needed under Criterion 8. Holland wrote that "he has not sustained a marked impairment in social functioning," leaving him unable to establish the three marked impairments required across the four domains assessed.
Definity had paid pre- and post-104-week income replacement benefits until stopping payments on December 31, 2023. Holland found the applicant proved he remained completely unable to engage in any employment suited to his education, training or experience, citing his exclusively physical work history in construction and psychological assessments describing a guarded prognosis. She ordered Definity to reinstate the benefit at $400.00 per week from January 1, 2024 to June 8, 2026, plus interest.
The applicant also sought a special award for unreasonable delay in paying benefits. Holland declined, finding Definity relied on valid medical opinions and considered the available evidence in adjusting the claim.
