Wawanesa has defeated a claimant's bid to escape Ontario's Minor Injury Guideline, with a tribunal upholding its denial letters and rejecting chronic pain claims.
The Ontario Licence Appeal Tribunal has dismissed an application against Wawanesa Mutual Insurance Company, finding that a driver injured in an October 2018 automobile accident could not push his claim beyond the $3,500 cap of the Minor Injury Guideline.
The applicant sought statutory accident benefits after the insurer refused to fund physiotherapy and two assessments. He argued his injuries fell outside the MIG, pointing to a chronic right shoulder condition and a psychological impairment, and said the plans had been submitted after the guideline's 12-week window.
The adjudicator was not persuaded. She found that simply submitting further treatment plans does not automatically remove a claimant from the MIG, and that the burden stays with the applicant to prove his injuries are not predominantly minor. Once the $3,500 in MIG treatment is completed, she held, it is the applicant's onus to show he belongs outside the guideline.
On chronic pain, the tribunal applied the "but for" causation test from Sabadash v. State Farm and found the medical record did not support a link to the accident. It noted a significant lapse in the applicant's records between November 2018 and August 2020, with no explanation provided. It also noted that when the applicant reported shoulder pain in July 2022, the records tied it to picking up an air conditioner three days earlier - not the collision.
The adjudicator gave little weight to a chronic pain assessment prepared nearly five years after the accident, observing that its author found the diagnoses were "probably directly related" to the crash. That word, she found, was not conclusive.
The psychological claim fared no better. The tribunal found the supporting assessment, completed almost five years post-accident, rested on the applicant's self-reports and lacked corroboration in his family physicians' records. It also found the applicant had not disclosed an earlier psychological history noted in clinical records, which undermined the credibility of the psychological findings.
The applicant also argued the insurer's denial letters breached the notice requirements in section 38(8) of the Schedule, relying on Varriano v. Allstate. The tribunal disagreed. It found each letter identified the disputed plan, explained the services were denied because the injuries were minor, and confirmed the medical evidence had been considered. An insurer, it noted, is not required to list every document it reviewed or to fabricate medical reasons where a claimant has supplied no supporting evidence.
Having found the denials compliant and the injuries within the MIG, the adjudicator held there was no need to assess whether the disputed plans were reasonable and necessary. Because no benefits were overdue, she awarded no interest and declined a special award under section 10 of Regulation 664, which allows up to 50 per cent of benefits payable where an insurer unreasonably withholds or delays payment.
The application was dismissed. The decision was released June 22, 2026.
