Ontario's licence tribunal has confirmed an auto insurer need not pay a non-earner benefit while it awaits insurer's examination results.
The Licence Appeal Tribunal (LAT) dismissed a claimant's bid for a non-earner benefit of $185.00 per week from December 5, 2024, in a decision released July 13, 2026. The claimant was injured in an automobile accident on November 7, 2024, and sought benefits under Ontario's Statutory Accident Benefits Schedule after Security National Insurance Company denied the claim.
The claimant submitted an application and a disability certificate in November 2024. By letter dated November 28, 2024, Security National said it could not determine eligibility from the certificate alone and required physiatry and occupational therapy insurer's examinations. It added that the benefit was not payable until it received the reports and reached a determination.
The claimant argued the insurer was obligated to pay the benefit during the assessment period, calling the delay contrary to the consumer-protection nature of the Schedule. The Tribunal disagreed. It found that section 36(4) gives an insurer three options after receiving a disability certificate - pay the benefit, arrange an examination, or request further documentation - and does not require payment to begin before the examination results arrive.
Further denials followed. By letters dated April 7 and April 28, 2025, Security National advised the claimant she was not entitled to the benefit, relying on examination reports from a physiatrist, an occupational therapist and a psychologist, each of whom found she did not suffer a complete inability to carry on a normal life.
The claimant also argued the insurer could not raise new points at the hearing beyond those in its denial letters. The adjudicator rejected that reading of section 54, finding nothing that confines an insurer's submissions to its denial correspondence.
On the merits, the Tribunal found the claimant had not met her burden. She relied largely on the disability certificate, but the adjudicator held that "an OCF-3 on its own is not medical evidence" and pointed to the absence of clinical records from treating practitioners. A psychological assessment diagnosing several conditions did not address how her pre- and post-accident activities compared - the comparison at the heart of the non-earner benefit test.
The Tribunal gave weight to the examination findings, noting the occupational therapist had charted the claimant's self-care, productivity and leisure activities before and after the accident. It found she had not shown a complete inability to carry on a normal life.
With no benefit owing, the claimant received no interest. Her request for an award under section 10 of Regulation 664 - available where an insurer unreasonably withholds or delays benefits - was refused, the Tribunal finding no unreasonable delay. The application was dismissed.
For insurers and claims professionals, the decision underscores where the burden sits in a non-earner benefit dispute. A disability certificate on its own did not carry the claim, and the insurer's decision to await its examinations before paying was upheld.
