An Ontario insurer's 15-month delay in completing claimant examinations just cost it over $117,000 - including a special penalty for unreasonably withholding or delaying benefits.
In a decision released on April 20, 2026, the Licence Appeal Tribunal ordered Dominion of Canada General Insurance Company (Travelers) to pay statutory accident benefits, interest, and a 25% special award after finding the insurer took too long to process a home modifications claim - and then relied on flawed assessments to deny it.
The case - Muir v. Dominion of Canada General Insurance Company (Travelers), 2026 CanLII 37052 (ON LAT) - was filed in November 2024 and heard by way of written submissions.
Linda Muir was in an automobile accident on November 25, 2020, and suffered an L2 spinal fracture that left her with severe lower back pain, weakness, and repeated falls. She lived in a two-storey home with ten porch steps and no main-floor bathroom. An occupational therapist assessed her home shortly after the accident and recommended a porch lift, stair lift, and main-floor bathroom. A treatment plan totaling $88,942.31 was submitted to the insurer on August 5, 2021.
The insurer denied it five days later and said examinations would be arranged. What followed was a 15-month process that Adjudicator Melanie Malach called "patently unreasonable." The insurer scheduled and rescheduled multiple assessments - orthopaedic, occupational therapy, neurological, and construction engineering - but never produced a construction engineering report. The final denial did not arrive until November 8, 2022.
Here is where it gets interesting. The insurer's own occupational therapy assessor, who visited Muir's home in person, concluded the modifications were functionally reasonable and necessary. She even had to physically assist Muir on the stairs during the visit to prevent a fall. The insurer denied the claim anyway, leaning on a virtual orthopaedic assessment that found the modifications unnecessary because the fracture had healed.
The Tribunal gave that virtual report no weight. The adjudicator found the assessor failed to address Muir's functional limitations and was asked the wrong question - whether modifications were needed for pre-existing conditions rather than accident-related injuries. The applicant also submitted that the insurer had not provided the assessor with complete records. The Tribunal reaffirmed that virtual assessments carry less evidentiary weight than in-person evaluations, consistent with earlier decisions.
Applying the "but for" causation test - the accident need not be the sole cause of an impairment, just a necessary one - the Tribunal found the fracture led to the functional limitations requiring modifications under Section 16 of the Statutory Accident Benefits Schedule.
The Tribunal also approved $3,976.16 for physical rehabilitation and $2,200.00 for a neuropsychological assessment, rejecting the insurer's position that Muir had reached maximum medical recovery. The only denied claim was $630.40 for housekeeping expenses, as Muir had not purchased optional coverage for that benefit.
On top of the approved benefits and interest, the Tribunal imposed a special award of $22,235.58 - 25% of the home modifications treatment plan - under Ontario Regulation 664 for unreasonably withholding or delaying payment. The adjudicator weighed the insurer's conduct, Muir's vulnerability, the harm from the delayed modifications, and the need to deter similar handling.
All told, the insurer's exposure exceeds $117,000 - a pointed reminder that how a claim is handled matters just as much as whether it gets paid.
