An Ontario tribunal ordered TD General Insurance to pay an award after finding it unreasonably withheld accident benefits despite holding supporting medical evidence.
The decision came from the Ontario Licence Appeal Tribunal on June 17, 2026, and hands claims professionals a pointed reminder about re-adjusting a file when new evidence arrives.
The applicant was hurt in a January 16, 2020 collision. Her car sat in a line of vehicles waiting for a school bus to proceed through a railway crossing when a third vehicle struck another at near highway speed, driving it into the back of her car. She sought benefits under the Statutory Accident Benefits Schedule, and TD General Insurance denied several of them.
Vice-Chair Robert Maich reviewed five disputed treatment claims. Two physiotherapy plans - for $1,796.00 and $1,515.17 - could not proceed because they had already been decided in an earlier proceeding, and res judicata barred the applicant from raising them again.
On a $1,910.00 claim for massage, osteopathy and personal training, the applicant had no approved treatment plan on file. TD argued the expenses were not payable without prior approval under section 38(2) of the Schedule. The tribunal took something from each side. Relying on Cargnelli v Aviva Insurance Company, Maich found the treatments payable during a denial period even without an approved plan, but capped the rate at the Professional Services Guideline figure of $58.19 per hour. That produced $1,571.13 for roughly 27 hours of treatment.
A second claim, for $1,640.00, rested on a treatment plan TD had approved years earlier. TD tried to exclude it for late disclosure and to challenge its rate after the fact. Maich rejected both moves, finding the insurer had held the plan for years and could not rescind an approval it had already given. Only $346.20 remained in that plan, so that was all the applicant recovered. A further $140.00 claim failed once the plan was exhausted.
The sharper finding was on conduct. The applicant sought an award under section 10 of Regulation 664, which lets the tribunal add up to 50 per cent of benefits payable where an insurer unreasonably withholds or delays payment. TD argued its handling was not immoderate and that insurers are held to reasonableness, not perfection.
Maich split the two contested claims. On the first, he found TD had a reasonable legal position and could not be held liable for an award. On the second, he found the insurer's conduct "unreasonable, stubborn and inflexible," noting it held medical evidence confirming the treatment was reasonable and necessary yet refused to re-adjust the file. He set the award at the lower end - 25 per cent, or $86.55 - because the relevant plan may not have been readily apparent to the insurer.
The applicant was also awarded interest on overdue benefits. The decision was released June 17, 2026, by Vice-Chair Maich.
An insurer with a reasonable legal basis for a denial drew no award; one that held confirming medical evidence and declined to re-adjust did.
