Definity Insurance Company must fund part of a chronic pain assessment after a tribunal removed an accident claimant from the minor injury cap.
An Ontario Licence Appeal Tribunal adjudicator ruled on June 17, 2026 that a driver injured in a December 15, 2022 collision had chronic pain with a functional impairment, taking him outside the Minor Injury Guideline and its treatment ceiling.
The dispute turned on whether the applicant's injuries were predominantly minor. Under the Statutory Accident Benefits Schedule, medical and rehabilitation benefits are "limited to $3,500.00" when an insured's impairments are predominantly a minor injury such as a sprain, strain or whiplash associated disorder.
Definity had denied benefits, arguing the applicant's evidence did not establish chronic pain or chronic pain syndrome. The insurer relied on a section 44 report by an orthopaedic surgeon dated February 25, 2025. But the adjudicator noted that report did not address chronic pain and did not have the applicant's other medical reports.
Two doctors supported the claimant. A physical medicine and rehabilitation specialist diagnosed chronic pain in the right hip, and an orthopaedic surgeon diagnosed chronic pain syndrome in a section 25 medicolegal report. The applicant, whose work is labour intensive, returned to his job the day after the accident and continued full-time duties, but reported pain while working and managed it with over-the-counter medication.
Definity challenged the reliability of that evidence, pointing to a lack of treatment after August 2023, limited pain medication, and infrequent contemporaneous complaints. The adjudicator was not persuaded. He accepted that the applicant stopped treatment because he was held within the guideline and could not fund further sessions while carrying an outstanding balance of $2,500.00. Family doctor records, he found, showed contemporaneous complaints of hip and back pain despite a gap between November 2023 and June 2025.
Removal from the guideline did not open the door to every benefit claimed. The adjudicator denied two physiotherapy plans valued at $4,008.50 and $199.50, finding no treating physician had recommended further physiotherapy and that the applicant had not shown the plans were reasonable and necessary.
The claimant fared better on a proposed chronic pain assessment. The plan sought $2,825.00, covering a $2,000.00 assessment, $200.00 for form completion and $300.00 for transportation. The adjudicator approved $2,200.00 plus applicable tax, finding the assessment and form fees reasonable for a complex evaluation by an orthopaedic surgeon, but rejecting the transportation cost as unsupported by the evidence.
The applicant was also awarded interest on any overdue benefits under the Schedule.
For insurers and claims professionals, the decision is a reminder that a functional impairment can lift a claimant out of the minor injury cap, yet each treatment and assessment plan still stands or falls on its own supporting evidence.
