A rigid insistence on an in-person examination - and a hasty benefits suspension - cost one Ontario auto insurer a 25% special award.
The Ontario Licence Appeal Tribunal, in a decision released July 20, 2026, ordered Gore Mutual Insurance Company to resume suspended non-earner benefits and pay a special award after adjudicator Melanie Malach found it had unreasonably withheld payments to an injured claimant.
The claimant was involved in an August 16, 2023 automobile accident and sought a non-earner benefit of $185.00 per week. Gore Mutual suspended those payments twice: first on January 14, 2025, citing non-compliance with a request for medical records under section 33 of the Statutory Accident Benefits Schedule, and again on February 5, 2025, after she did not attend an examination under oath.
On the records issue, the tribunal accepted that the claimant had a reasonable explanation for the delay. Her newly retained representative did not receive the accident benefits file until December 23, 2024, then began requesting clinical notes from third parties. The adjudicator found that reliance on a third party to produce records is not within a claimant's control, and that documents were forwarded to the insurer as they arrived.
The examination under oath drew sharper criticism. The insurer scheduled a one-day in-person session in Brampton for January 23, 2025, which the claimant did not attend. Her representative repeatedly asked for a virtual examination, citing documented mobility limitations, incontinence and psychiatric issues. The tribunal noted the insurer gave no specific rationale for insisting on an in-person format and did not address the claimant's stated reasons.
Section 33(4) of the Schedule requires an insurer to make reasonable efforts to schedule an examination at a time and location convenient for the applicant. The adjudicator found the original session did not meet that standard. The claimant ultimately attended a three-day examination in Collingwood in July 2025, held three hours per day, with transportation, a wheelchair and a personal support worker provided - accommodations the tribunal said showed she could not have managed the original all-day sitting.
Under section 33(8), an insurer must resume payment and repay withheld amounts once a claimant complies and offers a reasonable explanation for delay. The tribunal ordered benefits reinstated for the January 14 to August 16, 2025 period, with interest.
It then turned to section 10 of Regulation 664, which lets the tribunal award up to 50% of benefits payable where an insurer has unreasonably withheld or delayed them. The adjudicator found Gore Mutual gave no weight to the claimant's new counsel or the time third parties need to produce records, took a hard line on the in-person examination, and had still not reinstated benefits even after she complied. The conduct, the adjudicator wrote, was "excessive, imprudent, stubborn, inflexible, unyielding, or immoderate."
The insurer was ordered to pay a 25% award on the suspended benefits, plus 2% interest under Regulation 664.
