An Ontario tribunal faulted Certas for benefit denials too murky for laypeople, approving most disputed claims while sparing the insurer a special award.
The decision, Abdullah-Mohd v Certas Home and Auto Insurance Company, 2026 CanLII 56658 (ON LAT), was released June 5, 2026 by adjudicator Harouna Saley Sidibé after a written hearing.
Raedah Abdullah-Mohd was injured in an automobile accident on February 28, 2020, and claimed statutory accident benefits. Certas denied a series of treatment and assessment plans, and she brought the dispute to the Licence Appeal Tribunal's Automobile Accident Benefits Service.
By the time of the hearing, Abdullah-Mohd had withdrawn her income replacement and attendant care benefit claims. That left a cluster of disputed assessment and treatment plans, a claim for interest, and a request for a special award.
Sidibé sided with the applicant on five plans: psychological services, a neurological assessment and electromyography testing, a biopsychosocial assessment, an ENT assessment, and a sleep quality assessment. Much of that result turned on how Certas wrote its refusals.
Under sections 38(8) and 38(11) of the Schedule, an insurer that fails to give adequate medical and other reasons for denying a plan must pay for it for the period running from the eleventh business day after the plan is received until a proper denial is delivered.
Sidibé found several of Certas's denials fell short. The reasons were mostly conclusory, leaned on generalized references to earlier assessments, and did not explain how those findings applied to the specific services proposed. The adjudicator also criticized the format. Repeated pointers to "see additional comments," without clear corresponding explanations, left the rationale difficult to follow and inaccessible to a layperson.
On the merits, Sidibé also found each of the five assessments reasonable and necessary, citing ongoing complaints of pain, dizziness, sleep disruption, and possible psychological symptoms documented in the applicant's clinical records.
Certas fared better on the chiropractic plans. The adjudicator found the contemporaneous records pointed to physiotherapy and exercise-based rehabilitation, with no treating practitioner recommending chiropractic care. Giving greater weight to a section 44 orthopaedic opinion from Dr. Fathi Abuzgaya, Sidibé held that Abdullah-Mohd had not shown the chiropractic treatment was reasonable and necessary, and dismissed those three plans.
The insurer also avoided a special award under section 10 of Regulation 664, which allows the tribunal to order up to 50 percent of benefits payable where an insurer unreasonably withholds or delays payment. Although some denials were brief and thin on analysis, Sidibé found they were grounded in medical opinions obtained during claim adjustment. The shortcomings, the adjudicator concluded, were better understood as deficiencies in explanation than as unreasonable conduct.
Abdullah-Mohd was awarded interest on the overdue benefits under section 51 of the Schedule.
For claims professionals, the ruling is a pointed reminder that the clarity and adequacy of a denial, not only the strength of the underlying medical opinion, can determine whether an insurer ends up paying.
