An Ontario tribunal ordered Definity Insurance Company to pay income replacement benefits after it failed to chase a missing disability certificate during a priority dispute.
The Licence Appeal Tribunal released its decision on June 18, 2026, resolving a statutory accident benefits dispute.
The claimant was driving a ride sharing vehicle when an automobile accident occurred on December 4, 2022. Unsure whether to claim through his personal insurer or his employer's insurer, he filed two Applications for Accident Benefits (OCF-1) - one with Definity, his employer's insurer, and one with Certas, his personal insurer.
Definity received its OCF-1 on December 22, 2022. A disability certificate (OCF-3), required before income replacement benefits can be assessed, was faxed to Certas by Hands on Health on December 29, 2022. In a January 19, 2023 letter, Definity acknowledged the OCF-1 but said no OCF-3 had been submitted, and told the applicant he was not entitled to the benefit.
On February 22, 2023, Certas issued a Notice of Priority Dispute, signalling that the applicant had filed with it as well. That date became pivotal. Adjudicator Nadia Mauro found that once Definity was on notice of the competing claim, it should have asked Certas whether a completed OCF-3 had been received.
Under section 36(4) of the Statutory Accident Benefits Schedule, an insurer must respond to a completed application and disability certificate within 10 business days. Section 36(6) requires the insurer to pay the benefit for any period it remains non-compliant. The adjudicator noted that Ontario's priority rules require the first insurer to receive an application to pay benefits pending resolution of any dispute over which insurer must ultimately respond.
Mauro rejected Definity's argument that the application to Certas was of no ultimate consequence. She found the insurer had submitted no evidence of what steps, if any, it took after Certas raised the priority dispute. That silence, she wrote, was "fatal to any assertion that the respondent did not 'receive' an OCF-3."
The adjudicator was also unpersuaded that Definity's letters amounted to repeated requests for the document. A September 26, 2023 letter stated the benefit was not payable and added that no action was required - language she found was not a request at all.
The result: Definity was non-compliant with section 36(4) from February 22, 2023, when the priority dispute began, until January 26, 2024, when it sent a letter requesting further information under section 33. Mauro found that January 26 letter compliant, because it was sent within 10 business days of confirming receipt of the OCF-3 and sought information to determine eligibility.
The tribunal ordered Definity to pay income replacement benefits of $119.08 per week from February 22, 2023 to January 26, 2024, plus interest under section 51. The applicant did not establish entitlement for December 11, 2022 to February 21, 2023, or from January 27, 2024 to July 26, 2024.
For claims professionals, the decision turns on what an insurer does after a priority dispute surfaces. Accepting or adjusting a claim carries an obligation to make reasonable inquiries for outstanding documents - and a thin evidentiary record can decide the outcome.
