Intact Insurance lost its bid to claw back a five-figure income replacement benefit overpayment after Ontario's accident benefits tribunal found its repayment notices non-compliant.
The dispute arose from a December 11, 2019 automobile accident. The applicant, a self-employed music teacher, was rear-ended and sought statutory accident benefits from Intact. The tribunal released its decision on July 13, 2026, following a written hearing.
The central claims lesson concerns how Intact tried to recover an income replacement benefit overpayment. Beginning May 15, 2023, the insurer reduced the applicant's weekly benefit by 20 per cent, citing an overpayment of $15,748.33 for the period December 18, 2019 to April 3, 2023. Intact said the benefit had been recalculated after her pre-accident income was reassessed, and pointed as well to her later eligibility for CPP-Disability benefits.
Under section 52 of the Schedule, an insurer that overpays can generally recover only amounts paid in the 12 months before it gives a valid repayment notice - unless the overpayment resulted from wilful misrepresentation or fraud. Intact expressly disclaimed any such allegation, telling the applicant "at no time are we implying any wilful misrepresentation or fraud." Because its April and May 2023 notices demanded the full amount dating back to December 2019 rather than the 12-month window, the adjudicator, Ulana Pahuta, found the notices invalid and ordered the withheld benefits repaid.
The applicant fared better on the central issue. Pahuta found she was catastrophically impaired under Criterion 8 of the Schedule, which requires a marked impairment in at least three of four spheres of functioning, or an extreme impairment in one, arising from a mental or behavioural disorder. She was awarded income replacement benefits of $165.05 per week from May 15, 2023, and ongoing.
Other claims did not succeed. Although attendant care benefits had been framed at $10,644.24 per month, the applicant conceded a $6,000 monthly maximum, and the tribunal awarded $3,526.30 per month - the only figure supported by a Form 1 in evidence - and only once expenses are incurred. Her $168,181.92 claim for home modifications was denied for lack of supporting assessment evidence, as were several treatment plans for physiotherapy, occupational therapy and medical cannabis.
For insurers, the most reassuring finding may be the last. The applicant sought a special award under section 10 of Regulation 664, which lets the tribunal add up to 50 per cent of benefits payable where an insurer unreasonably withholds or delays payment. Pahuta declined. Even though Intact's repayment notices were found non-compliant and its catastrophic impairment denial did not hold up, its conduct did not meet the high bar for the kind of unreasonable behaviour a special award requires. An award, she noted, should not follow merely because an insurer made an incorrect decision.
