An Ontario tribunal granted a claimant catastrophic impairment status, but a missed deadline and a paperwork gap blocked tens of thousands in benefits.
The decision in O'Keefe-Burns v Primmum Insurance Company, 2026 CanLII 56640 (ON LAT), released June 5, 2026, came out of an automobile accident on February 12, 2020. Shannon O'Keefe-Burns sought benefits under the Statutory Accident Benefits Schedule, was denied by Primmum Insurance Company, and brought the dispute to the Licence Appeal Tribunal.
The headline finding went to the claimant. Adjudicator Tami Cogan determined that O'Keefe-Burns reached a Total WPI Criterion 7 Combined rating of 56%, surpassing the 55% threshold for a catastrophic determination. The claimant had argued for 67%; Primmum argued for 30%. The adjudicator landed in between after working through the parties' competing assessor ratings line by line.
Much of the gap turned on hearing loss. The claimant's otolaryngologist assigned 21% WPI for bilateral hearing loss, while the respondent's otolaryngologist, Dr. Mark Korman, assigned 0% but allowed that 17% would apply if the loss was tied to the accident. Cogan accepted the 17% rating and found, on a balance of probabilities, that "the accident is the cause of the applicant's hearing loss." She was not persuaded by Korman's view that the head impact was insignificant, noting luggage struck the applicant in the head and that he had not considered her cervical fracture.
For claims professionals, the procedural rulings carry the practical weight. O'Keefe-Burns submitted an OCF-6 for attendant care services of $44,961.89 dated June 24, 2022, which Primmum denied on June 29, 2022. She did not dispute that denial until filing her Tribunal application on June 23, 2025, outside the two-year limitation period under s. 56 of the Schedule. Cogan found the denial was proper, the claimant was advised of her right to dispute, and there were no reasonable grounds to extend the limitation period under the Manuel factors. The claimant was statute barred from a hearing on that claim.
The hearing-aid claim failed on different grounds. The claimant sought $1,650.00 for hearing aids, submitted on an OCF-6 on July 15, 2024 and denied on September 4, 2024. Cogan found the hearing aids reasonable and necessary, since the claimant had been prescribed them and used them daily. But the expense exceeded the $250.00 ceiling allowed without a treatment plan, and no OCF-18 was submitted before the expense was incurred, as s. 38(2) requires. The claimant was not entitled to reimbursement.
The insurer also defeated the bid for a special award. Under s. 10 of Reg. 664, the Tribunal may award up to 50 per cent of benefits payable where an insurer unreasonably withholds or delays payment. Cogan found Primmum's denials rested on medical evidence, that an insurer is entitled to rely on its examinations, and that disagreement between assessors does not make either patently incorrect. She found no unreasonable delay and no award owing, and no interest was payable.
The takeaway for accident-benefits insurers is concrete. A catastrophic finding does not rescue claims that miss the limitation clock or skip the OCF-18 step, and properly evidenced denials can withstand a special-award challenge.
