Ontario tribunal backs The Personal Insurance Company in accident benefits dispute, ruling insurers need not cite medical evidence a claimant never provided.
The Ontario Licence Appeal Tribunal dismissed Adam Smai's application against The Personal Insurance Company on May 22, 2026 in Smai v The Personal Insurance Company, 2026 CanLII 51002 (ON LAT). The decision offers claims professionals practical reinforcement on two recurring fronts: Minor Injury Guideline removal arguments built on chronic pain, and the standard for compliant denial letters under section 38(8) of the Statutory Accident Benefits Schedule.
Smai was injured in an automobile accident on July 15, 2020. He sought coverage for three chiropractic treatment plans from 101 Physio - dated September 22, 2020, March 12, 2021, and May 13, 2021 - in the amounts of $2,469.11, $2,659.11, and $2,613.91 respectively. The Personal classified his injuries as minor and held him to the $3,500 MIG cap.
Smai argued he should be removed from the MIG on chronic pain grounds, citing neck, back, and predominantly knee pain. Adjudicator Jeff Chatterton was not persuaded. The first clearly legible reference to knee pain in his family physician's records was February 16, 2022 - nearly 19 months after the accident. The records also referenced a foot splint dated August 20, 2019, supporting the insurer's argument that foot and knee issues predated the collision. An orthopedic surgeon diagnosed patellofemoral syndrome, or runner's knee, in March 2023, but those notes did not link the condition to the accident. The insurer also noted Smai was a member of his high school basketball team, a point Smai did not refute.
The adjudicator concluded ongoing pain alone is not enough. The pain must cause "suffering and distress accompanied by functional impairment or disability." There was no diagnosis of chronic pain, and minimal evidence that pain interfered with work, family, or recreation.
The section 38(8) ruling may be the more useful takeaway for claims handlers. Smai argued The Personal's three denial letters - dated September 26, 2020, March 17, 2021, and May 21, 2021 - used vague, boilerplate language and failed to identify the evidence relied upon. Each letter stated the insurer had reviewed the listed injuries, found no pre-existing conditions described, compared them to the MIG criteria, and concluded the injuries fell within the Guideline.
The insurer responded that it had made multiple attempts to obtain medical evidence from Smai and could not fabricate a medical reason where none existed. Chatterton agreed, finding the reference to the MIG and a minor injury classification a valid medical reason. He held that an insurer cannot be expected to refer to evidence that does not exist, and pointed out that the medical records Smai later relied upon postdated the denial letters by at least eight months. Dr. Hahn's diagnosis came two years after the denials were issued.
All three denial letters, the adjudicator found, offered a principled rationale based on the file information available at the time. No interest was payable, and the application was dismissed.
