TD General Insurance Company had reasons to contest a $2,200 benefit claim - but a generic denial letter meant it had to pay anyway.
That was the upshot of a recent decision from the Ontario Licence Appeal Tribunal, released on April 16, 2026, in the case of Missra v. TD General Insurance Company. The ruling is a fresh reminder that how an insurer communicates a denial matters just as much as whether the denial itself is justified.
The case stems from a February 3, 2020 car accident. Amit Missra applied for statutory accident benefits and eventually brought several disputes to the Tribunal, including three claims for medical cannabis totalling over $11,000 and one claim for a $2,200 social work assessment.
On the cannabis claims, the insurer won cleanly. Adjudicator Jeff Chatterton found that Missra had not shown the treatment was reasonable and necessary - and the most damaging evidence came from Missra himself. During an insurer's examination on November 25, 2022, he reported using cannabis for four weeks but could not point to any clear benefit. When re-examined on December 19, 2024, he described the improvement from cannabis as roughly 10 percent - compared to 20 to 30 percent from Tylenol. The Tribunal drew on similar reasoning from Capone v. Wawanesa Mutual Insurance Company, 2024 CanLII 94143 (ON LAT), where a cannabis claim was denied after the applicant acknowledged the treatment was not helping.
But the social work assessment went the other way - and not because the Tribunal found the treatment was warranted on its merits.
TD denied the assessment in a letter dated November 9, 2022. The letter read: "[b]ased on all of the medical documentation we have on file, it does not support the requested treatment plan." That was it. The Tribunal found this to be boilerplate - language that did not address the applicant's specific condition or explain why, medically, the treatment was being refused.
Under section 38(8) of the Statutory Accident Benefits Schedule, an insurer has 10 business days after receiving a treatment plan to provide the medical and other reasons for a denial. If it fails to do so, section 38(11) kicks in: the insurer must pay.
TD did eventually raise an argument - that the assessment duplicated previously approved services. But that reasoning appeared for the first time in its Tribunal submissions, not in the original denial letter. The Tribunal was clear: reasons offered in litigation cannot fix a deficient denial after the fact.
Interest was also awarded on the overdue benefit under section 51 of the Schedule. The Tribunal declined to impose a penalty award, noting both that the applicant had not provided submissions on the issue and that the insurer's conduct did not rise to that level.
The lesson here is not complicated. Insurers that rely on template language in their denial letters risk paying for benefits they might otherwise have lawfully refused. The reasoning needs to be in the letter - not saved for the hearing room.
