Intact Insurance has defeated an accident claimant's bid to escape Ontario's $3,500 minor injury cap, with a family doctor's records proving decisive.
The Ontario Licence Appeal Tribunal dismissed the application on July 10, 2026, ruling that the claimant had not met the burden to be removed from the Minor Injury Guideline (MIG). The decision offers insurers and claims professionals a clear look at how contemporaneous medical records can outweigh competing expert reports.
The claimant was injured in an automobile accident on April 18, 2023, and sought statutory accident benefits. After Intact denied the benefits, he applied to the tribunal, arguing he should be removed from the MIG - and its $3,500 treatment limit - on two grounds: a pre-existing condition and an accident-related psychological condition.
Under section 18(1) of the Statutory Accident Benefits Schedule, medical and rehabilitation benefits are capped at $3,500 where injuries are predominantly minor. Section 3(1) defines a minor injury as a sprain, strain, whiplash associated disorder, contusion, abrasion, laceration or subluxation, including any clinically associated sequelae.
An insured can be removed from the guideline under section 18(2) by showing a documented pre-existing condition alongside compelling medical evidence that the condition precludes recovery within the MIG's limits.
On the first ground, the claimant pointed to a partial tear in the radial ligament of his left elbow, documented by his family physician in June 2021 and confirmed by ultrasound imaging in July 2021. The adjudicator accepted the pre-existing condition was documented but found the second part of the test unmet. The family physician did not opine that the claimant could not reach maximal medical recovery within the MIG.
On the psychological ground, the claimant relied on a section 25 report diagnosing Adjustment Disorder with Anxiety, Major Depressive Disorder and Vehicular Phobia, supported by a battery of standardized tests. Intact countered with a section 44 assessment. The insurer's assessor found no DSM-5 diagnoses, psychological symptoms or impairments, and reported that testing showed the possibility of symptom magnification in certain areas.
The adjudicator gave significant weight to the family physician's clinical notes, describing the doctor's long-term, OHIP-funded relationship with the claimant as "objectively neutral." Those records contained no psychological complaints, and the adjudicator was not directed to any such complaints made to any other medical provider.
The claimant's psychological report was given reduced weight because it did not align with the preponderance of the medical evidence. The insurer's opinion was preferred as more consistent with the absence of reported symptoms to the family doctor.
With the claimant held to the MIG, the adjudicator found it unnecessary to assess whether the disputed treatment plans were reasonable and necessary.
The tribunal also rejected a claim for a special award under section 10 of Regulation 664, which allows an award of up to 50 per cent of benefits payable where an insurer unreasonably withholds or delays payment. Because no benefits were found overdue, no award and no interest were payable.
The application was dismissed.
