What happened: A claimant tried to move her injuries outside Ontario’s $3,500 minor-injury cap. She did not succeed.
Who’s involved: Co-operators General Insurance Company, a claimant and Ontario’s Licence Appeal Tribunal.
What’s at stake: Five treatment plans worth more than $15,000, against a $3,500 limit on medical and rehabilitation benefits.
Why it matters: The tribunal weighed two diagnoses against the family doctor’s records and the claimant’s daily activities.
Where it stands: Decided September 16, 2026; the tribunal dismissed the application.
Two experts assessed the same claimant about a month apart and came back with very different answers.
The psychological assessment diagnosed PTSD and major depressive disorder. The psychiatric assessment, done a month earlier, found her symptoms most consistent with a mild adjustment disorder with anxiety.
Ontario’s Licence Appeal Tribunal went with the psychiatric assessment in a decision released September 16, 2026. That kept the claimant inside the Minor Injury Guideline, the rule that limits medical and rehabilitation benefits to $3,500 when injuries are mostly minor, like sprains, strains and bruises. Getting out from under it was her job to prove.
Co-operators General Insurance Company had denied her benefits after a May 26, 2022 car accident. Five treatment plans were in dispute, from $2,215.58 for chiropractic care to $4,395.29 for psychological services. Add them up and they top $15,000.
The tribunal never had to decide whether any of those plans were reasonable or necessary. The cap question came first.
She had two ways out of the cap, and she tried both. One was shoulder pain she said had become chronic. The other was a psychological injury from the accident. Either could have worked if she proved it.
On the shoulder, she pointed to a March 2023 note from her family doctor about chronic left shoulder pain, limited movement and a partial rotator cuff tear. Co-operators said imaging did not confirm the tear and the doctor stopped noting chronic shoulder pain afterwards.
The tribunal accepted she had accident-related pain. The records, though, described soft-tissue complaints treated with physiotherapy and symptom management. They held no chronic pain diagnosis and no referral for specialized assessment. Pain that lasts, the tribunal said, does not by itself put an injury outside the minor category.
She was back at work about a week after the accident and stayed there until she went on leave in September 2022.
Co-operators also pointed to the family doctor’s notes from March 28, 2025, which had her driving, doing housework, walking about 10,000 steps a day and using light weights. That did not make her symptom-free, the tribunal said. It did matter to whether her pain was lasting and disabling enough to count.
The psychological side came down to a face-off between assessments. In March 2023, the claimant told her family doctor about nightmares and flashbacks while driving. The doctor noted an impression that included PTSD and referred her for psychotherapy.
The psychiatric assessment, dated June 21, 2023, concluded she was not psychiatrically impaired, though it suggested she talk to her family doctor about antidepressants. The psychological assessment followed on July 22, 2023.
Co-operators relied on the first. The claimant relied on the second.
The tribunal accepted her symptoms were real and said the psychological assessment did not lose weight just because it leaned partly on her own account. It still went with the psychiatric view, which it found fit the family doctor’s records better.
Those records documented anxiety, driving fear, nightmares and avoidance. They did not consistently show the wider symptoms behind the PTSD and depression diagnoses, and when she saw her family doctor on March 6, 2023, she denied depression.
Her daily functioning backed that up, the tribunal said. By the time of the assessment she was driving several times a week despite the anxiety and staying in treatment, and she came across as cooperative, fully oriented and able to give a detailed history.
The tribunal flagged one more mismatch. The psychological assessment’s history says the claimant struck her head in the accident. Ambulance and hospital records indicate she denied it.
The tribunal said the mismatch was not decisive, but it did lower the weight of the parts of the report that leaned heavily on that retrospective history.
With the claimant inside the cap, the tribunal dismissed the application, skipped the treatment plans and found no interest owing because no overdue amounts remained.
It did not question that her anxiety was real or that it warranted treatment. Inside the cap, though, medical and rehabilitation benefits top out at $3,500. What carried the most weight was how well each assessment matched the family doctor’s records and what the claimant was doing day to day.
The tribunal decided the case on written submissions. This article is based on the tribunal’s decision and is not legal advice.
