Ontario's tribunal held a claimant to the $3,500 minor injury cap, citing an uncorroborated psychological report and unproduced medical records.
The dispute arose from a July 5, 2022 automobile accident, after which the applicant sought statutory accident benefits from Pembridge Insurance Company. The insurer denied the disputed benefits and treated the injuries as predominantly minor, holding him to the $3,500 limit under Ontario's Minor Injury Guideline. The applicant asked the Licence Appeal Tribunal to be removed from that cap on the basis of psychological impairments.
For claims professionals, the decision turned on evidence and procedure rather than any novel point of law. The applicant relied on a psychological assessment conducted on May 18, 2023 and reported on July 10, 2023, prepared by a registered psychotherapist under the supervision of a psychologist. It diagnosed adjustment disorder with mixed anxiety and depressed mood, and a situational specific phobia related to vehicles. The applicant said he continued to experience anxiety, sleep disturbance and emotional distress that interfered with his daily functioning and ability to work.
Adjudicator Georgina Blanas was not persuaded. She found the assessment was not corroborated by the rest of the medical record. Apart from that single report, the applicant produced no records from a mental health professional showing an ongoing accident-related psychological impairment. Clinical notes from a medical centre he attended after the accident - dating to a first visit on November 1, 2022, roughly four months after the crash - recorded sleep problems and neck, finger and shoulder complaints, along with a recommendation for psychotherapy, but contained no psychological diagnosis and documented no ongoing treatment.
Blanas also noted the assessment was completed about ten months after the accident and rested largely on the applicant's self-reported symptoms. "I place limited weight on the assessment," she wrote.
A second problem compounded the first. At the case conference, the applicant had been ordered to produce clinical notes and records, OHIP summaries, imaging records and prescription records. He did not produce everything the order required, his submissions did not address the failure, and he offered no explanation. The records were within his control. Blanas took their absence into account in weighing whether he had met his burden of proof, which in every MIG removal case rests with the applicant.
On that record, the tribunal found the applicant had not shown, on a balance of probabilities, a psychological impairment warranting removal from the guideline. Because he remained within the MIG, Blanas held it unnecessary to decide whether the disputed treatment plans - two for psychological services and one for physiotherapy - were reasonable and necessary. The plans exceeded the funding available under the cap and were not payable.
The applicant also sought interest and a special award under section 10 of Regulation 664, available where an insurer unreasonably withholds or delays payment. Blanas found no benefits were overdue and that the insurer had not withheld payment, and denied both. The decision, heard in writing, was released on June 25, 2026.
