A raft of accident benefit claims against Wawanesa exposed how tightly Ontario's Licence Appeal Tribunal scrutinizes treatment-plan billing, file reviews and denial letters.
The claimant was injured on September 29, 2021, as a passenger in a vehicle that was rear-ended. Citing her pre-existing fibromyalgia, degenerative conditions with radiculopathy, chronic back and neck pain, and carpal tunnel syndrome, Wawanesa Mutual Insurance Company removed her from the $3,500 Minor Injury Guideline funding limit on April 4, 2022. She went on to dispute the insurer's refusal to pay several accident benefits treatment plans before the Tribunal, later withdrawing a catastrophic impairment claim and a related $11,639 assessment dispute ahead of a written hearing.
In a decision released August 7, 2026, adjudicator Ulana Pahuta found the claimant entitled to just $798.44, plus interest, for psychological treatment. Every other disputed claim - covering massage expenses, a chiropractic balance, and a catastrophic file review - was dismissed.
The psychological treatment plan drew the closest scrutiny of any billing item. It proposed four therapy sessions at $149.61 each, alongside four "documentation support activity" charges and five "planning, service" charges billed at a combined $310.22 per session - more than double the cost of the actual treatment. Pahuta approved the therapy sessions and a $200 form completion fee but rejected the administrative add-ons outright, noting the claimant had not explained what the services entailed or why they cost more than the clinical treatment itself.
A separate $2,486 claim for a comprehensive file review tied to a catastrophic impairment assessment was also denied. Wawanesa had argued a file review isn't payable as a stand-alone expense but forms part of each individual assessment, already captured within the Schedule's $2,000 funding cap for catastrophic assessments. Pahuta agreed, relying on two prior Tribunal decisions to find the review was bundled into assessments the insurer had already funded.
The claimant also argued Wawanesa's denial letter for that file review breached the Schedule by failing to give medical reasons. Pahuta disagreed, finding the denial rested on non-medical grounds - that file reviews simply aren't separately billable - and that insurers aren't required to manufacture a medical rationale for a non-medical refusal. The letter was found "adequate to allow an unsophisticated person to understand the denial."
Two smaller claims turned on procedural and rate discipline. A $220 massage expense submitted on an expense form rather than a treatment plan was denied under section 38(2) of the Schedule, since the claimant offered no evidence that an exception applied. And a $21.72 shortfall on a chiropractic treatment plan was upheld because the plan's $60 hourly massage rate exceeded the $58.19 maximum set by the Professional Services Guideline, with no evidence offered to justify the higher rate.
The Tribunal's order leaves the claimant's recovery limited to the $798.44 psychological treatment award, with interest running on that amount under section 51 of the Schedule. The remaining treatment plans and the OCF-6 claim form were dismissed in full.
