Wawanesa avoided paying for two benefit denial notices sent a business day late, after Ontario's Tribunal found no expenses were shown incurred during the delay.
The Licence Appeal Tribunal dismissed an application for statutory accident benefits stemming from a September 10, 2022 automobile accident, in a decision released July 24, 2026. The applicant sought a series of treatment plans from Wawanesa Mutual Insurance Company, including a psychological assessment, a psychological pre-screening report, psychological services, an attendant care assessment, a chronic pain assessment, and physiotherapy services, with disputed amounts ranging from $300 to $4,801.30.
Rather than pointing to medical evidence to support removal from Ontario's Minor Injury Guideline (MIG), which caps medical and rehabilitation benefits at $3,500 for injuries defined under the Schedule as including a "sprain, strain, whiplash associated disorder, contusion, abrasion, laceration or subluxation," the applicant argued that Wawanesa's denial notices did not comply with section 38(8) of the Schedule. That section requires an insurer to explain its medical reasons for denying a treatment plan within 10 business days.
Adjudicator Ulana Pahuta found that MIG determination and notice compliance are separate issues. Even where an insurer misses the section 38(8) deadline, section 38(11) only prevents that insurer from denying the specific treatment plan on MIG grounds - it does not permanently remove a claimant from the MIG. Because the applicant provided no medical evidence or argument for removal, his claim failed on that basis alone.
On the timing dispute, the Tribunal found that two of Wawanesa's denial letters - covering a psychological services plan worth $4,801.30 and an attendant care assessment worth $2,400 - were issued one business day after the 10-day deadline, based on the actual online submission date logged for each plan. However, the Tribunal held that section 38(11) only obliges an insurer to pay for services that were actually incurred during the period of non-compliance. Since the applicant did not show any expenses were incurred during that single business day, no payment obligation was triggered on either treatment plan.
The decision also confirmed that a denial letter can satisfy section 38(8) simply by referencing insufficient medical evidence of a non-minor injury or psychological impairment, without addressing every piece of medical documentation an applicant submits. Denials that pointed to hospital records, clinical notes, and later insurer examination reports - including from a psychologist and an occupational therapist - were found to provide adequate medical reasons throughout the dispute.
The Tribunal also reviewed several physiotherapy funding disputes, finding Wawanesa's partial approvals and one further denial were issued within the required timeline and adequately explained by reference to the MIG's pre-approved funding limits.
Ultimately, the Tribunal found the applicant had not established grounds to be removed from the MIG, was not entitled to any of the disputed treatment plans, and was not owed interest. It also declined to order a special award under section 10 of Regulation 664, which permits an award of up to 50 per cent of benefits payable where an insurer unreasonably withholds or delays payment, finding no benefits had been unreasonably withheld or delayed.
