An insurer that omitted a psychological report from its denial notice must now pay for treatment it refused - but escaped a penalty.
On June 22, 2026, Ontario's Licence Appeal Tribunal decided a statutory accident benefits dispute arising from a July 28, 2021 automobile accident. The applicant was denied benefits by Pembridge Insurance Company and turned to the Tribunal to resolve it.
The adjudicator found the applicant subject to the Minor Injury Guideline, which caps medical and rehabilitation benefits at $3,500. The applicant led no evidence to support removal from the guideline, so that limit held.
The dispute turned instead on how the insurer denied treatment. A plan proposing $6,184.34 in psychological services was rejected through an Explanation of Benefits in March 2023. Yet the insurer already held a psychological assessment report, dated January 9, 2022, diagnosing the applicant with conditions including Major Depressive Disorder and a situational phobia. The denial notice never mentioned it.
The adjudicator found the notice failed to comply with section 38(8) of the Schedule, which requires insurers to give specific medical and other reasons an unsophisticated person can understand. Because the report was already in the insurer's possession, omitting it meant the notice did not reveal the insurer's reasoning. Under section 38(11), the consequence followed automatically: the insurer must pay the $6,184.34 plan once incurred.
The insurer's later steps did not fix the problem. A section 44 examination notice issued in July 2025 repeated the earlier shortcomings, and a November 2025 denial - following an examination by a neuropsychologist - still failed to address the earlier psychological report or explain why the applicant's reporting was rejected.
A second plan, for $4,342.74 in physiotherapy, drew a different result. The insurer responded 16 business days after receiving it, past the 10-day deadline, but the adjudicator found those reasons compliant, citing an unexplained treatment gap of more than three years and a lack of objective findings. The lateness alone triggered a narrow shall-pay window: the plan is payable only if incurred between February 7 and 14, 2025.
The applicant also sought a special award of 50 per cent of the benefits under section 10 of Regulation 664, arguing the insurer had unreasonably delayed. The adjudicator refused. A deficient notice, the Tribunal held, does not by itself amount to unreasonable withholding; an award requires conduct that is "immoderate, imprudent, stubborn, inflexible, or indifferent to its obligations."
Even a roughly 27-month gap between signalling an insurer examination and compelling it did not clear that bar. The delay, the adjudicator found, reflected poor file progression grounded in the insurer's reliance on the family physician's records rather than an effort to withhold benefits improperly. The applicant was awarded interest on any overdue payments under section 51.
