A $2,486 neurosurgery claim just failed at Ontario's accident benefits tribunal - and the reason is one every auto insurance claims professional should note.
The case did not turn on a dramatic legal argument or a disputed policy clause. It turned on paperwork - or rather, the lack of it. On April 17, 2026, the Licence Appeal Tribunal issued its ruling in Sivathasan v. TD General Insurance Company, a straightforward win for the insurer.
Sivamathy Sivathasan was involved in a car accident on November 11, 2022. She noted difficulty with walking, pain in her right knee and shoulder, and numbness in her right hand. More than a year later, a physician submitted a treatment plan proposing a neurosurgery assessment, along with preparation and documentation support, at a total cost of $2,486.00. TD General Insurance Company denied it, and Sivathasan brought the matter to the Tribunal.
The decision from Adjudicator Timothy Porter was unambiguous. Sivathasan had not met the threshold required to justify payment for the proposed assessment. Under the applicable rules, the burden falls on the claimant - not the insurer - to show that a proposed treatment or assessment is reasonable and necessary as a result of the accident.
What sank the case was the treatment plan itself. The adjudicator flagged a telling list of what it failed to include: no indication of what diagnosis or course of treatment was being explored, no identification of barriers to recovery, no recommendations for overcoming them, no mention of any concurrent treatment, and no supporting attachments. The physician did not appear to be aware of any functional limitations the claimant was experiencing. As the adjudicator put it, the plan was "silent on what diagnosis or course of treatment is being explored."
There was another problem. Sivathasan had already been seen by a neurosurgeon through OHIP - Ontario's public health system - along with multiple neurologists and an orthopaedic surgeon, all at no cost to her. The adjudicator found no evidence that the neurosurgeon who had assessed her was unqualified or unavailable, or that she had any reason to be dissatisfied with the care already provided. The public system had, in effect, already covered the ground the proposed assessment was meant to cover.
Sivathasan also asked the Tribunal to sanction TD General Insurance Company for allegedly withholding or delaying payment - a move that could have added up to 50 percent of any benefits found to be payable. That request was denied, as no benefits were found to have been unreasonably withheld or delayed. The claim for interest was denied as well, since no benefits were found to be owing.
For claims teams, the takeaway is straightforward. A treatment plan that leaves too many questions unanswered is unlikely to survive any serious review.
