Citing OHIP billing codes alone won't cut it for insurers trying to deny accident benefit assessments, a new LAT ruling confirms.
In a decision released on April 23, 2026, the Licence Appeal Tribunal sided with a claimant on two of four disputed medical assessments - while handing the insurer wins on duplication, IRB interest, and a penalty claim. The case, Jones v. Definity Insurance Company, 2026 ONLAT 24-015021/AABS, touches on some of the most commonly litigated questions in Ontario accident benefits and offers a few pointed reminders for claims teams.
The facts are straightforward enough. William Jones, a 61-year-old bus driver, fractured his C7 and T1 vertebrae in a November 2022 car accident. Nearly two years later, All Health Medical Centre proposed four assessments on his behalf - psychological ($2,200), orthopaedic ($2,580), chronic pain ($2,320), and physiatry ($2,580). Definity Insurance declined to fund them.
The core question on three of the four assessments was whether Jones could have accessed the same services through OHIP - the availability defence under the Statutory Accident Benefits Schedule. Adjudicator Bernard Trottier found the answer depended entirely on the evidence.
On the orthopaedic assessment, Definity won. The Tribunal noted that Jones had already seen an orthopaedic spine surgeon at the Hamilton General Fracture Clinic under OHIP and had been referred back for a follow-up by his own doctor. That was enough to shift the burden to Jones to show the service wasn't reasonably available through the public system. He couldn't.
The chronic pain and physiatry assessments were a different story. Definity pointed to OHIP billing codes A425 and A313 and argued a general practitioner could perform both. The Tribunal wasn't persuaded, finding that these assessments are typically handled by specialists - and that billing codes on their own don't prove a GP could deliver the same thing.
The psychological assessment raised a separate issue. Definity had denied the treatment plan but then sent Jones for an insurer's examination with psychologist Dr. Christopher Friesen, who acknowledged symptoms of depressed mood. The Tribunal found it would be unfair to let the insurer examine the claimant through its own assessor while denying him the chance to be assessed by one of his choosing - a principle drawn from the earlier Z.E.A.R. v. Gore Mutual decision. The assessment was approved.
On the physiatry claim, the insurer caught a break. The Tribunal found the assessment's goals were essentially identical to the chronic pain assessment - both proposed by All Health - and that Jones hadn't shown how they were materially different. It was denied as duplicative.
The IRB interest claim also went the insurer's way. Jones argued Definity had enough information to calculate his income replacement benefits by June 2024 and sat on the file for months. But the Tribunal found that Jones hadn't submitted key documents - a complete disability certificate and employer confirmation form - until early 2025, and that the insurer's documentation requests were reasonable. No interest was owed. A penalty award was likewise denied.
