An Ontario tribunal has ruled insurers may deny a benefit while awaiting a medical exam and the limitation clock keeps running.
The Licence Appeal Tribunal, in a decision released July 28, 2026, dismissed a claimant's bid for accident benefits stemming from a 2022 car accident. Adjudicator Aric Bhargava upheld TD General Insurance Company's decision to keep her treatment within Ontario's $3,500 Minor Injury Guideline (MIG) and found several of her disputes filed too late to proceed.
The applicant sought statutory accident benefits from TD after the May 27, 2022 accident, including a non-earner benefit and funding for physiotherapy, psychological services and several assessments. TD denied the claims, arguing her injuries were predominantly minor and fell within the MIG's treatment cap. She took the dispute to the Tribunal.
Before reaching the merits, the adjudicator first had to decide whether three of the disputed benefits - physiotherapy services, psychological services and a neuropsychological assessment - were barred by the two-year limitation period in the Schedule. TD's original denial letters for those three items were sent in July and November 2022, while the applicant did not file her application until December 4, 2024.
Two of those letters denied funding for assessments while noting that a section 44 insurer's examination was still pending. The applicant argued the pending exam meant TD's refusal was not final, and that the two-year clock should not have started. The adjudicator disagreed, finding that a pending exam was itself an acceptable "other" reason for a denial, and that requesting an exam does not undercut an otherwise clear and unequivocal denial. The adjudicator further found that a later denial issued once exam results come in does not restart the two-year limitation period. As a result, all three of those disputed benefits were found statute-barred.
Two other disputed items - a non-earner benefit and a psychological assessment - were denied by a January 23, 2023 letter, which put them within the two-year window when the application was filed. On the merits, though, the applicant fared no better. Her family doctor's records tied her anxiety diagnosis to academic stress rather than the accident, and her abdominal complaints were attributed to irritable bowel syndrome or gastroesophageal reflex disease rather than a functional impairment from the crash. The adjudicator found she had not met her burden to show a psychological impairment or chronic pain sufficient to escape the MIG, and dismissed her claim for the non-earner benefit of $185 per week as well.
With no benefits found owing, no interest was payable, and the Tribunal declined to order a special award, finding no evidence TD had acted unreasonably in handling the file. The application was dismissed in full.
For claims teams, the ruling offers a practical takeaway: a denial letter that flags a pending insurer's examination as the reason for withholding payment can still start the limitation clock, and a later, post-exam denial does not give a claimant a fresh two-year window to dispute the original decision.
