What happened: An Ontario tribunal moved a forklift operator's crash claim outside the $3,500 minor injury cap.
Who's involved: CAA Insurance Company and an injured claimant whose benefits it denied.
What's at stake: $400 a week in income replacement benefits from August 7, 2025, onward, plus interest.
Why it matters: Lasting pain that limits work can break the cap, even when the claimant's expert falls flat.
Where it stands: Decided October 5, 2026; treatment plans and a penalty award were denied.
An occupational therapist assessing a forklift operator for CAA Insurance found that "he does not meet the physical demands of his pre-accident job."
That finding ended up on the claimant's side of the ledger.
In a decision released October 5, 2026, Ontario's Licence Appeal Tribunal moved his claim outside the $3,500 Minor Injury Guideline (MIG) limit. It also ruled he is entitled to $400 a week in income replacement benefits from August 7, 2025, onward, plus interest.
CAA still won two rounds. The tribunal threw out three disputed treatment plans and turned down a penalty award.
The crash happened on October 26, 2024. CAA denied the claim, pointing to pre-existing impairments, and argued the injuries were soft tissue damage that belonged inside the cap.
Here is why that cap matters. Ontario's accident benefits rules limit medical and rehabilitation benefits to $3,500 when injuries are mostly minor, such as sprains, strains and whiplash. Claimants can break out by proving, among other things, chronic pain that limits what they can do.
CAA first argued the crash did not cause his shoulder problem. To back that up, it pointed to family doctor records, including an x-ray suggesting older changes in the spine.
The tribunal spotted a catch. The x-ray was of his neck, not his shoulder.
Emergency room records showed pain in both shoulders right after the crash, and a November 2024 ultrasound found a partial tear and bursitis that the tribunal tied to the accident. He later had shoulder surgery.
The tear alone was not his ticket out. Partial tears fit within the minor injury definition, the tribunal said. What counted was the pain that dragged on for months afterward.
The claimant's orthopaedic expert told the tribunal he met all six chronic pain criteria in the American Medical Association's impairment guides. The tribunal was not sold. It found the opinion leaned mainly on self-reported symptoms and was not well backed by the evidence.
Take the criterion on prescription drug overuse. The expert pointed not to the claimant's prescription history but to his non-prescription marijuana use.
"The criterion requires evidence of medication abuse or dependence on prescribed drugs," the tribunal wrote.
CAA's examining physician did not fare much better. He concluded the right shoulder and knee pain were not accident-related, but the tribunal trusted the emergency room and family doctor records made right after the crash.
So what won it? The functional evidence. The occupational therapist found the claimant "showed significant reduction in mobility of the right shoulder," measured its range of motion at 65 degrees, and found he could not push, pull, lift or carry with his right arm.
That spelled trouble for his job. As a shipper, receiver and order picker, he worked in the cold, stood continually and ran a forklift, reach trucks, a dock-stocker and a walkie. The tribunal found his shoulder would keep him from those core tasks, which is the test for income replacement benefits, and his family doctor wrote on three separate dates that he could not work.
The tribunal cut him some slack on deadlines. His psychological assessment arrived 36 days late and other records up to 82 days late, but the tribunal let them in, finding they were worth more to the case than the prejudice to CAA.
It cut him none on the treatment plans. He wanted $4,654.79 for physiotherapy and two psychological plans worth $2,144.93 and $3,409.09, but he never explained why they were reasonable and necessary, only that treatment helped and some was denied.
"The applicant cannot simply submit evidence and leave it up to the Tribunal to connect the dots and make his case," the tribunal wrote.
The penalty bid fell flat too. He sought an award of up to 50 per cent of the benefits under section 10 of Regulation 664, which applies when an insurer unreasonably withholds or delays payment. CAA said he never sent his income details, and the tribunal found nothing "excessive, imprudent, stubborn, inflexible, unyielding or immoderate" in how it handled the claim.
Losing on the cap and the income benefit did not make CAA's denial unreasonable. In the tribunal's words, "an insurer is not held to a standard of perfection."
A partial tear on an ultrasound will not break the cap on its own, but months of documented pain that keeps someone off the job can, and here CAA's own assessment helped document it.
The decision does not say whether either party plans to seek reconsideration or appeal.
