A vague denial letter just cost an Ontario insurer thousands of dollars - even though the insurer was right on the merits.
In a decision released on April 16, 2026, the Licence Appeal Tribunal ordered Certas Home and Auto Insurance Company to pay a $3,774.50 physiotherapy treatment plan it had successfully argued was not reasonable or necessary. The catch? Its Explanation of Benefits did not meet the notice standards required under the Statutory Accident Benefits Schedule.
The case stems from a November 10, 2022 automobile accident involving Zixin Lin, who sought coverage for two treatment plans submitted by UHeal Rehab Centre - a $4,217.20 chiropractic plan dated April 10, 2023, and a $3,774.50 physiotherapy plan dated June 17, 2024. Certas denied both.
On the substance, Adjudicator Kathleen Wells sided with the insurer on both counts. The clinical notes of Lin's family doctors contained no complaints of accident-related physical pain, no diagnosis of physical injuries from the accident, and no referrals for physiotherapy. Lin's first visit to his family doctor came more than a month after the accident and focused on sleeplessness and nightmares - not physical symptoms. While Lin later reported pain to a psychologist roughly 20 months after the accident, the Tribunal found those self-reports were not enough to fill the gap left by the absence of contemporaneous medical records.
That should have been the end of it. But the procedural side of the case told a different story.
Under the Schedule, an insurer must respond to a treatment plan within ten business days, spelling out which goods and services it will and will not cover, along with medical reasons for any denial. If it fails to do so, the insurer can be required to pay for the treatment plan during the period of non-compliance.
The Tribunal examined three separate denial notices from Certas and found two of them lacking. The April 21, 2023 notice referenced "your list of injuries" without identifying what those injuries were, and stated that "recommendations must address your diagnosis" without explaining whether the proposed treatment actually did. The June 25, 2024 notice used the term "facility-based treatment," which the Tribunal found would not be understandable to an unsophisticated person.
A third notice, dated May 22, 2024, passed the test. That one specifically pointed to the absence of accident-related physical impairment complaints in the physician's records - a concrete, identifiable reason for denial.
Because no compliant denial was ever issued for the physiotherapy plan, the Tribunal ordered Certas to pay the full $3,774.50, once incurred and properly invoiced, plus interest. Lin's request for a penalty award was denied.
The takeaway for claims teams is plain: being right about the medicine is not enough if the paperwork does not hold up.
