Primmum Insurance Company's own examiner rejected a driver's psychological injury claim three separate times - the tribunal sided with her treating psychologist anyway.
The applicant sought statutory accident benefits after a motor vehicle accident on May 5, 2022, including funding for physiotherapy, psychological services, a neurological assessment, a physiatry assessment and a driving evaluation assessment. Primmum Insurance Company denied the plans, and the dispute went to Ontario's Licence Appeal Tribunal.
The most closely contested issue was the applicant's psychological services plan, worth $3,692.40. Primmum's position rested on a psychologist who assessed or reviewed the applicant's file three times - in October 2023, in a December 2023 paper review, and again in August 2025 - each time concluding there was no compelling evidence of a psychological diagnosis tied to the accident. The applicant instead relied on an assessment diagnosing adjustment disorder with mixed anxiety and depressive symptoms, a sleep disorder, and somatic symptom disorder with predominant pain; a related treatment plan recommended fifteen sessions of psychotherapy.
Adjudicator Sarah Guergis found the applicant met her onus to show the plan was reasonable and necessary, noting the applicant had already been removed from Ontario's Minor Injury Guideline in an earlier, related tribunal decision involving her psychological injuries. On the competing assessments, Guergis found the insurer's evidence should not carry more weight simply because it was gathered in person, reasoning that "a physical or in-person assessment is less significant" where the injury at issue is psychological rather than physical.
A driving evaluation assessment, worth $1,945.72, was also found payable. The applicant, a civil engineer who said driving was required for her career, had reported anxiety about driving and being a passenger on multiple occasions to her family doctor and psychologist. Primmum argued she had waited a year and seven months after the accident before first raising the concern, but Guergis found the evidence of ongoing driving-related anxiety was sufficient to warrant the assessment.
A neurological assessment, worth $2,520.00, was similarly approved. Guergis found the applicant's reported headaches, dizziness and fatigue warranted further investigation, despite the absence of a formal neurological diagnosis.
Two physiotherapy plans, worth $5,287.29 and $961.03, along with a separate physiatry assessment worth $2,520.00, were found not payable. Guergis ruled the applicant had not been pointed to compelling evidence of ongoing physical injury or functional limitation to justify the further treatment.
Interest is owing on the three payable plans. The tribunal declined to order a special award against Primmum, finding the applicant had not been pointed to evidence the insurer unreasonably withheld payment. The decision was released August 4, 2026.
For claims professionals, the case shows that repeat insurer examinations, even from the same expert, do not automatically beat treating evidence when the injury in dispute is psychological rather than physical.
