An Ontario tribunal ordered Wawanesa to pay a 50% penalty award after the insurer refused to apply a prior ruling that settled a causation dispute.
The Licence Appeal Tribunal decision, released July 20, 2026, offers claims professionals a pointed lesson on when an insurer's examination shifts from diligent adjusting to over-testing.
The claimant was injured in a May 3, 2013 automobile accident and sought statutory accident benefits from Wawanesa. In an earlier proceeding, the Tribunal had already found she sustained a catastrophic impairment under criterion 8, a mental and behavioural impairment.
At issue was her entitlement to attendant care benefits of $6,000 per month. The insurer arranged an occupational therapy examination to assess those needs, but the assessor gave no opinion and instead requested a psychiatric examination to gauge the extent of the claimant's psychiatric impairments.
The claimant refused to attend, arguing the request was an attempt to relitigate causation the Tribunal had already settled. Wawanesa countered that the examination was reasonable because attendant care tied to mental and behavioural impairment fell outside the occupational therapist's scope.
The vice-chair sided with the claimant. Applying factors drawn from a 2018 Travelers decision, he found the psychiatric examination was being requested more frequently than reasonably necessary. The deciding factor was that no genuinely new issue required evaluation - the causation dispute had been resolved in the earlier ruling.
The insurer, he noted, could have simply handed the assessor that earlier decision to reconcile the differing medical opinions and spare the claimant a further intrusive assessment, but chose instead to insist on a fresh opinion.
With the claimant permitted to proceed, the Tribunal deemed the benefits incurred under section 3(8) of the Schedule, accepting that her limited finances - she cannot work and relies on disability income - kept her from paying for the full care herself.
The Tribunal then addressed the special award under section 10 of Regulation 664, which allows a penalty of up to 50% of benefits payable where an insurer has unreasonably withheld or delayed them. It found the insurer's conduct "stubborn and inflexible," because it would not apply the prior decision that had resolved the causation question troubling its own assessor.
The vice-chair awarded 50% of the attendant care benefits withheld from July 23, 2025 - the date the claimant submitted her assessment form - to the date of the decision, plus interest.
For claims teams, the ruling is a reminder that the right to test entitlement, while real, is not absolute. The insurer had argued it was not held to a standard of perfection and was entitled to test both entitlement and quantum. The Tribunal accepted that principle but found this insurer had let a settled causation issue drive an unnecessary examination and a prolonged denial.
