Intact Insurance beat a claimant's bid to escape Ontario's minor injury cap - but a flawed denial letter still triggered a non-earner benefit payout.
The Ontario Licence Appeal Tribunal released its decision on June 26, 2026, following written submissions. The dispute arose from an automobile accident on October 16, 2023, after which the claimant sought statutory accident benefits and was denied by Intact.
The central question was whether her injuries were predominantly minor, keeping treatment within the $3,500 Minor Injury Guideline (MIG) limit. She argued that persistent physical pain and psychological symptoms placed her outside the guideline.
The adjudicator disagreed. He accepted that she reported ongoing pain consistent with a chronic pain presentation, but found the evidence did not show functional impairment inconsistent with a minor injury. Contemporaneous records documented only conservative management - massage, medication, and modified work - and a December 7, 2023 cervical spine X-ray showed degenerative changes without acute structural injury. The insurer's orthopaedic examiner diagnosed a right sacroiliac sprain with a favourable prognosis, and its emergency medicine examiner found no objective ongoing impairment.
On the psychological claim, the adjudicator found no formal assessment or diagnosis linking symptoms to the accident. The insurer's psychologist identified only subclinical features of an adjustment disorder and raised concerns about the validity of the claimant's presentation. Her impairments were therefore predominantly soft-tissue sprain and strain injuries within the MIG, so the Tribunal did not need to assess the disputed treatment and assessment plans.
Where Intact stumbled was the paperwork. The claimant sought a non-earner benefit of $185.00 per week. Her disability certificate, completed October 23, 2023 by a chiropractor, indicated she suffered a complete inability to carry on a normal life. Intact's November 6, 2023 denial letter said the opposite - that the certificate showed no such inability - and on that basis found her ineligible.
The adjudicator found the denial timely, issued within the 10-business-day window, but non-compliant with section 36(4) of the Schedule. Citing Smith v. Co-Operators, 2022 SCC 30, the decision noted a denial must give clear, accurate reasons an unsophisticated insured can understand. Here, the stated medical reason mischaracterized the certificate's contents.
Under section 36(6), that non-compliance obliged Intact to pay the benefit from November 13, 2023 - seven days after it received the completed certificate - until a compliant denial was issued, subject to the statutory maximum of 104 weeks after the accident. No compliant denial followed. Notably, the adjudicator stressed the claimant had not established substantive entitlement; she was paid because of the process failure, not the merits. Interest applies under section 51.
Intact avoided a further penalty. The claimant sought a special award under section 10 of Regulation 664, which allows up to 50 percent of benefits payable where an insurer unreasonably withholds or delays payment. The adjudicator declined, finding the insurer had assessed the claim and relied on available information, and that its conduct was not "excessive, imprudent, stubborn, inflexible, unyielding, or immoderate." The award claim was dismissed.
