An Ontario insurer lost nearly every accident benefit dispute at tribunal, yet avoided a special award for unreasonable claims handling.
The Licence Appeal Tribunal released its decision on August 4, 2026, in a dispute between an applicant injured in an automobile accident on February 13, 2022, and Definity Insurance Company. The applicant had sought several benefits under the Statutory Accident Benefits Schedule that the insurer had denied, and asked the tribunal for a special award on top of the disputed amounts.
Adjudicator Jim Zotalis found the applicant entitled to a speech-language assessment, an adaptive kitchen setup with pull-out shelving, a baby shower chair, a powered recliner chair, and a home accessibility assessment, plus interest on the overdue amounts. On the kitchen and shower chair claim, the tribunal gave little weight to a functional abilities evaluation report submitted on the insurer's behalf, noting the report appeared to reference a different individual entirely and questioning its accuracy as a result.
The applicant was also partially entitled to speech-language treatment and therapeutic yoga. On the speech-language plan, the tribunal declined to order payment for $2,019.96 in provider travel time, finding it unreasonable to retain a provider located more than 400 kilometres away when treatment could be delivered virtually or locally. On the yoga plan, the tribunal found no provision under the Schedule for provider travel time at all, and reduced the hourly rate for an unregulated provider to $58.19, the maximum set out in the Professional Services Guideline, down from the $98.75 proposed.
A separate list of everyday assistive devices produced a mixed result. The applicant sought a robotic vacuum, a callus remover, blue light glasses, a smart watch fall detector and a non-slip cutting board. The robotic vacuum was denied as an existing household appliance she already owned. The callus remover was denied because a nurse already provided that care every six weeks. The blue light glasses and the cutting board were denied for lack of medical evidence supporting the need for either. Only the fall detector was approved, on the basis that a wearable device was more practical than requiring her to carry a phone at all times.
Despite losing on nearly all of the substantive issues, Definity was not ordered to pay a special award under section 10 of Regulation 664, which permits an award of up to 50 percent of benefits owed where an insurer unreasonably withheld or delayed payment. Zotalis found the insurer relied on its own medical examiners and reached a different conclusion than the applicant, without acting in a manner that was excessive, stubborn or unyielding. The standard an insurer must meet, the decision states, is "one of reasonableness, not perfection."
The decision leaves Definity liable for the assessment, the reduced treatment plans, the assistive devices ordered, and interest, with no special award attached.
