An Ontario tribunal kept a claimant within the $3,500 minor injury cap, but ruled Intact's notices failed to justify most of its treatment plan denials.
The applicant was injured in a car accident on February 4, 2023, and applied to the Licence Appeal Tribunal after Intact Insurance Company denied benefits under the Statutory Accident Benefits Schedule. The dispute centred on whether the applicant's injuries were predominantly minor, capping treatment at $3,500 under the Minor Injury Guideline (MIG), and whether Intact's notices explaining its denials of six treatment plans complied with section 38(8) of the Schedule.
Vice-Chair Rebecca Hines found the applicant had not met her onus of proving her injuries fell outside the MIG, since she made no submissions addressing what her impairments were or why the treatment plans in dispute were reasonable and necessary. The applicant instead argued that Intact's denial notices themselves failed to meet the Schedule's requirements.
Section 38(8) requires an insurer to notify a claimant within 10 business days of receiving a treatment plan of what it will and will not pay for, along with medical and other reasons. Under section 38(11), an insurer that misses that standard becomes liable to pay for the plan once the claimant incurs it, starting on the 11th business day, until a compliant notice is issued.
Hines found Intact's notices denying five of the six disputed plans - including a $1,100.32 treatment plan and a partial denial worth $396.99 - fell short of the standard, largely because Intact missed the 10-business-day window or gave no explanation tied to the applicant's medical information. On three further plans, worth $3,783.65, $3,546.65 and $3,461.90, Hines found Intact's earlier notices non-compliant but ruled that a later notice dated September 5, 2024 finally met the standard, limiting the applicant's entitlement to amounts incurred before that date. A sixth plan, for $3,225.05, was denied by a notice Hines found compliant, so the applicant recovered nothing on that item.
In her reasoning, Hines relied on the standard set out in the reconsideration decision T.F. v. Peel Mutual Insurance Company, under which a compliant notice should be "clear and sufficient enough to allow an unsophisticated person to make an informed decision" on whether to dispute it. She declined to follow Khalaf v. Aviva General Insurance, a separate Tribunal decision that had found a denial covering an entire treatment plan need not itemize each service to be adequate, concluding that approach was inconsistent with the standard set out in T.F. v. Peel.
One notice also referenced the Financial Services Commission of Ontario's Professional Services Guideline, which caps hourly fees for form completion; Intact had approved only $112.81 toward a $200 charge on that basis.
The applicant was awarded interest on the amounts found payable under section 51 of the Schedule.
For claims teams, the decision underlines that a bare reference to goods or services in a denial letter may not be enough on its own - notices still need to tie back to the applicant's medical information and identify the Schedule provisions relied on, even where the underlying MIG determination goes the insurer's way.
