At the centre of the case was the Minor Injury Guideline, which caps medical and rehabilitation benefits at $3,500 for impairments that are predominantly minor - sprains, strains, whiplash and similar soft tissue injuries. The applicant sought three disputed treatment plans, valued at $2,340.38, $4,671.58 and $3,415.28.
Aviva argued the claimant sustained no more than uncomplicated soft tissue injuries and remained within the cap. It relied on its examiner, a general practitioner who assessed the applicant more than two years after the accident and found self-resolving injuries with no valid signs of ongoing impairment.
The adjudicator gave that opinion less weight. She preferred the applicant's physiatrist, whose June 5, 2025 report concluded that documented pre-existing musculoskeletal conditions and a knee condition limited his ability to recover within the confines of the guideline. Under the Schedule, an insured can be removed from the cap by showing a documented pre-existing condition plus compelling medical evidence that recovery would not be achievable inside it.
The applicant's pre-accident record was extensive, including a prior rear-end collision, degenerative disc disease and chronic pain complaints documented by his family physician. The tribunal found that history, combined with the physiatrist's opinion, satisfied both requirements.
Causation was a live issue. The claimant was involved in a second collision on May 20, 2023, and Aviva argued he had not separated the impairments caused by each accident. The adjudicator found the relevant neck, back and radicular complaints were documented before the second crash - through a neurological assessment, a specialist consultation, a lumbar MRI identifying a disc protrusion and an OCF-3 - and traced them to the 2022 accident.
Aviva also tried to bar the hearing, citing the applicant's late production of clinical records and a decoded OHIP summary and his failure to attend three insurer examinations. The insurer had suspended medical benefits over the missed appointments. The adjudicator declined to bar the claim, noting the applicant later attended the insurer's musculoskeletal assessment and that Aviva held the relevant reports and records before the hearing. Because no specific expenses were tied to the non-compliance period, the issue did not affect the outcome.
The tribunal removed the applicant from the guideline, found all three treatment plans reasonable and necessary, and awarded interest on overdue amounts.
Aviva did avoid a penalty. The applicant sought a special award for benefits unreasonably withheld or delayed, which can reach 50 per cent of amounts payable. The adjudicator declined, finding "there was a reasonable basis for the respondent to dispute the applicant's medical presentation," pre-existing conditions, causation and the necessity of treatment.
