What happened: An Ontario tribunal ordered Unifund Assurance to pay for a psychological assessment it had denied with a vague, boilerplate letter.
Who's involved: Unifund Assurance Company and an auto accident claimant.
What's at stake: $2,144.93 for a psychological assessment, plus interest on the overdue period.
Why it matters: Insurers that deny treatment plans without specific medical reasons risk being forced to pay for the very benefits they tried to refuse.
Where it stands: Decided. The order was released on October 7, 2026.
Unifund Assurance Company denied a $2,144.93 psychological assessment - and the letter it sent to explain why said almost nothing at all.
That gap between "denied" and "explained" just cost the insurer months of ordered payments it could have avoided with a single page of specific reasoning.
Ontario's Licence Appeal Tribunal ruled on October 7 that Unifund's initial denial of the treatment plan broke the accident benefits rules because the letter lacked any meaningful medical detail. The insurer was ordered to cover the assessment - plus interest - for the roughly five-month window before a compliant denial letter finally arrived.
The case arose from a December 2022 auto accident. The claimant sought benefits under Ontario's Statutory Accident Benefits Schedule, including physiotherapy and a psychological assessment. Unifund denied both and placed the claimant within the Minor Injury Guideline (MIG), which caps treatment benefits at $3,500.
When the claimant's treatment plan for a psychological assessment landed with Unifund in November 2023, the insurer had 10 business days to respond with specific medical reasons if it wanted to say no. That is not optional - it is a core requirement under Ontario's accident benefits rules.
Unifund's December 9, 2023 letter did not clear that bar. It said the claim was denied, pointed to the Minor Injury Guideline, and noted that an independent medical examination had been arranged. No diagnosis. No prognosis. No reference to the claimant's actual injuries or the information the insurer had reviewed.
The tribunal found those reasons "insufficient," ruling the letter gave the claimant no real basis to decide whether to accept or challenge the denial.
The claimant's lawyer called the letter "flawed, arbitrary, inapplicable, not meaningful, and statutory deficient."
Unifund issued a second denial letter on May 13, 2024, this time backed by the findings of a psychologist it had retained to examine the claimant. That psychologist concluded the claimant had no significant accident-related psychological symptoms.
The tribunal accepted this second letter as compliant - it gave the claimant enough specific information to understand the decision and decide whether to dispute it.
But the fix came at a cost. Under the accident benefits rules, when a denial letter fails to meet the requirements, the insurer must pay for the denied treatment covering the period from the 11th business day after it received the treatment plan until a proper denial letter is issued. For Unifund, that window ran from roughly mid-December 2023 through May 13, 2024.
The claimant also tried a bolder argument: that Unifund's rule-breaking should pull him out of the Minor Injury Guideline entirely, opening the door to benefits well beyond the $3,500 cap. The tribunal rejected that, citing an Ontario Divisional Court ruling that found a flawed denial letter does not automatically remove a claimant from the guideline. The claimant still had to prove his injuries fell outside the MIG on their own merits - and a psychological pre-screen report based solely on self-reported symptoms was not enough without supporting evidence.
The physiotherapy claim was denied outright. A request for a penalty of up to 50% of benefits also failed because the claimant had not made specific submissions to support it.
The ruling is a clean reminder that denial letters are not a formality - a vague or templated refusal can turn a straightforward denial into an obligation to pay.
The findings in this decision are specific to the parties involved. The order was released on October 7, 2026.
