What happened: An Ontario tribunal reversed a ruling that had treated unbilled attendant care as already incurred.
Who’s involved: The Dominion of Canada General Insurance Company and a claimant seeking Ontario accident benefits.
What’s at stake: A $3,000-a-month attendant care benefit for January 5 to July 18, 2023.
Why it matters: Getting its own assessment after a claimant’s expert report was not, on its own, unreasonable, the tribunal said.
Where it stands: Ruled September 16, 2026. The insurer won some of what it asked for; the claimant’s request was dismissed.
An Ontario claimant was found entitled to $3,000 a month in attendant care. The tribunal also ruled that no payment is owing.
The Licence Appeal Tribunal took back part of its May 6 decision in a reconsideration ruling released September 16, 2026. The dispute is with The Dominion of Canada General Insurance Company, and both sides asked for a second look. Only the insurer got any change, and only in part.
The dispute grew out of a June 30, 2021 accident and a request for benefits under Ontario’s Statutory Accident Benefits Schedule. The original decision found the claimant entitled to the attendant care benefit from January 5 to July 18, 2023.
Two occupational therapy reports set those dates. The claim rested on one dated January 5, 2023. The insurer’s own, dated June 26, 2023, led it to cut the benefit off on July 18.
No bills. The parties agreed no attendant care invoices had been paid or submitted for payment.
The insurer said that since nothing was incurred, nothing was payable. The claimant said incurred expenses did not realistically reflect his need, and that he could not pay for the care he needed.
The insurer’s first argument was that there was nothing to decide. It said it had approved the benefit for those dates and was only waiting on the expense forms it had requested. The tribunal disagreed: the two sides could not agree on what records the insurer needed, and that alone made it a dispute.
On the merits, the original decision had relied on section 3(8) of the Schedule. It lets the tribunal treat a cost as incurred, so it counts even though nobody paid it, if an insurer’s unreasonable withholding or delay is why the cost never arose. The claimant also has to show he was entitled to the benefit.
On the bigger question, the vice-chair sided with the insurer. The original decision’s only finding of unreasonable behaviour, the vice-chair wrote, was that the insurer did not immediately have its own responding opinion when it received the claimant’s report.
That was the whole finding. The original decision did not find the insurer slow to review the report or to arrange its own assessment.
Insurers are not held to a standard of perfection, the tribunal added. If an insurer takes good-faith steps to assess a claim, withholding or delaying payment is unlikely to count as unreasonable. In the vice-chair’s words, it is “not unreasonable for an insurer to seek out its own opinions and evidence” when a funding request arrives.
The claimant had said the benefit was “wrongfully denied” and that he relied on his elderly parents for care as a result. The vice-chair found no convincing explanation for that argument. Covering the cost of a denied benefit is not, without more, unreasonable withholding, the vice-chair said, because every denial would then qualify.
The vice-chair also called the original reasoning logically inconsistent with another finding: that the insurer acted reasonably when it dismissed the claim based on its own assessor’s opinion.
The claimant’s own request went nowhere. He had asked for the benefit to continue from July 19, 2023 onward, and the tribunal dismissed that in full. Reconsideration, it said, is not a do-over for arguing about how much weight the evidence deserved.
The optometry assessment on one claim form is no longer payable. The insurer argued it was incurred before a related OCF-18 form was submitted, and the claimant offered no response. Payment for replacement glasses stays.
The final order sums it up: entitled to the benefit for those dates, “but no payment is owing.”
Under section 3(8), treating unbilled care as incurred takes unreasonable conduct by the insurer. Asking for its own assessment did not meet that bar, the tribunal found.
