Intact Insurance lost its bid to block a catastrophic impairment finding after an Ontario tribunal rejected its pre-existing condition arguments in an auto claim.
The Licence Appeal Tribunal ruled on July 7, 2026 that an accident claimant qualified as catastrophically impaired. The applicant was hurt in a September 25, 2021 collision and sought benefits under the Statutory Accident Benefits Schedule. After Intact denied the claim, he brought the dispute to the tribunal.
The sole question was whether he met the threshold for catastrophic impairment under Criterion 8. That criterion is met when an insured sustains three or more marked (Class 4) impairments, or one or more extreme (Class 5) impairments, from a mental or behavioural disorder, across four areas of function: activities of daily living, social functioning, concentration, persistence and pace, and adaptation.
The two sides agreed on most of the picture. Both the applicant's psychiatrist and the insurer's psychologist diagnosed major depressive disorder and somatic symptom disorder with predominant pain, and both accepted that the applicant already had marked impairments in daily living and adaptation. The entire case turned on one disputed rating: concentration, persistence and pace. The applicant's assessor rated it marked; the insurer's assessor rated it moderate. Whichever way that single rating fell would decide the catastrophic determination.
Intact built its position on the applicant's history. It pointed to limited household activity before the accident, 2010 social-assistance records referencing depression, his departure from the workforce, and a pandemic-era period of fentanyl use, two overdoses and incarceration, all offered as evidence of poor pre-accident functioning.
The adjudicator was not persuaded. He found the sparse household duties reflected the applicant's living arrangement with his mother rather than impairment, and treated the 2010 records as evidence of depressive symptoms without proof they had kept him from working. Pension contribution history pointed the other way: steady insurable earnings from 2012 to 2019, ranging from $27,288.00 to $55,900.00, which he read as proof of good functioning in a work setting. He gave little weight to the drug use and incarceration, finding no clear link to the disputed area of function.
On the medical evidence, the insurer's psychologist had concluded the applicant "demonstrated some ability to concentrate and pace." But functional testing by occupational therapists on both sides showed he could take in instructions yet could not persist beyond roughly 35 minutes. The adjudicator found that limitation significantly impeded useful functioning and rated concentration, persistence and pace as marked.
With three marked impairments established, the applicant met Criterion 8 and was found catastrophically impaired.
For claims professionals, the decision shows how a single contested area of function can decide an entire catastrophic determination. The adjudicator required a demonstrated link between the applicant's earlier difficulties and the disputed area of function before those difficulties could weigh against the claim, and he treated documented employment earnings as objective evidence of pre-accident capacity. Where the file comes down to one rating, the quality of functional testing and the strength of the causation link can carry the outcome.
