An Ontario tribunal has largely sided with an auto insurer, rejecting most of a claimant's disputed treatment claims and refusing to impose a penalty.
The Licence Appeal Tribunal resolved a statutory accident benefits dispute arising from a May 8, 2019 automobile accident. The claimant, injured in the crash, sought a series of medical and rehabilitation benefits under Ontario's Statutory Accident Benefits Schedule. North Blenheim Mutual Insurance Company had approved parts of several treatment plans but denied the balance, prompting the claimant to challenge the refusals through written submissions.
At issue were two psychological treatment plans and three occupational therapy plans. The tribunal found the claimant had not met his onus of proving the disputed psychological services were reasonable and necessary. The insurer had approved therapy and education sessions but denied provider travel time and mileage, relying on an examination that found the claimant had resumed driving and could tolerate roughly an hour behind the wheel. A separate psychological assessment described a resolving adjustment disorder at subclinical levels and recommended a limited course of additional sessions - findings the claimant failed to rebut.
The occupational therapy claims split. The tribunal rejected a November 2024 plan and a larger December 2024 plan, finding the stated goals vague and noting that some requested services resembled attendant care, which the claimant had already settled. It stressed that attaching medical records is not enough; the onus is on the applicant to point to specific evidence, not for the tribunal to search the file. But the claimant succeeded on a modest December 2024 plan for snow removal assistance and a shower stool, supported by an assessment documenting compromised balance and dizziness.
The claimant also sought a special award under section 10 of Regulation 664, which lets the tribunal order up to 50 per cent of benefits payable where an insurer unreasonably withholds or delays payment. The tribunal declined. It reaffirmed that such awards require conduct that is "excessive, imprudent, stubborn, unyielding or immoderate," and found the insurer's denials rested on current examination reports rather than outdated information. Even with part of one plan ultimately approved, the tribunal noted an insurer is not held to a standard of perfection.
Interest was ordered only on the approved snow removal and shower stool plan, under section 51 of the Schedule.
For insurers and claims professionals, the decision is a reminder that the evidentiary burden in accident benefits disputes rests firmly with the claimant. Denials grounded in timely, well-documented examinations withstood scrutiny, while a partial approval did not translate into a finding of unreasonable conduct. Carefully reasoned assessments, even when imperfect, defeated both the benefit claims and the threat of a penalty.
