An Ontario auto insurer's own medical exam handed a claimant an exit from the minor injury cap - then sank his income benefit bid.
The Licence Appeal Tribunal released its decision on June 29, 2026, resolving a statutory accident benefits dispute between a self-employed delivery worker and Nordic Insurance Company of Canada after a June 26, 2023 automobile accident. Nordic had denied benefits, and the claimant took the fight to the Tribunal.
The result was a split that should interest every claims professional. The claimant escaped the Minor Injury Guideline, which caps medical and rehabilitation benefits at $3,500.00. But he walked away with none of the disputed money.
What removed him from the cap was Nordic's own evidence. The insurer's examining psychologist diagnosed post-traumatic stress disorder and somatic symptom disorder, and the insurer accepted those diagnoses. Adjudicator Harouna Saley Sidibé held that PTSD and somatic symptom disorder are not minor injuries under the Schedule, placing the claimant outside the guideline even though his physical injuries stayed within it.
Escaping the cap, however, changed nothing on the ledger. The claimant sought $2,254.72 for a further psychological assessment. Sidibé found it unnecessary, reasoning that the insurer's examination had already produced a clear diagnosis and a defined treatment pathway, which made another assessment duplicative. He also denied a $322.55 balance on an accounting report, holding that the Schedule caps reimbursement for such reports at $2,500.00 and the claimant had shown no basis to exceed it.
The larger contest was the income replacement benefit, claimed at $233.87 per week. Here Nordic's multidisciplinary evidence proved decisive. The examining psychologist concluded the claimant retained capacity for part-time work; a neurologist found no neurological basis for a complete inability to work; and a vocational assessment identified suitable occupations. The claimant, self-employed in delivery work, had also kept working after the accident.
Sidibé found the claimant had not met the test. Post-104-week benefits require proof of a complete inability to engage in any suitable employment, and the adjudicator noted that "the post-104-week test is not met by reduced capacity, difficulty working, or diminished earnings." He added that working out of financial necessity did not outweigh the objective evidence of residual capacity. Citing the Superior Court's ruling in Paesano, he noted that post-104-week entitlement presupposes entitlement during the first 104 weeks.
Two preliminary defences also failed. Nordic argued the claim was barred because the claimant missed insurer examinations scheduled for March and April 2025. But he later attended rescheduled psychological and neuropsychological exams on June 24, 2025, and the insurer relied on the resulting reports. Sidibé held the earlier non-attendance had been cured, so no statutory bar applied. A separate document-production argument met the same fate.
Finally, the claimant sought a special award of up to 50 percent under section 10 of Regulation 664 for unreasonably withheld benefits. Sidibé declined. Nordic's denials rested on independent assessments, and he found nothing in its conduct that met the threshold for an award.
For claims professionals, the case shows how an insurer's independent assessments can cut in both directions - conceding the minor injury point while carrying the far larger income benefit and award questions.
