Can You Lose Accident Benefits for Missing an Insurer Exam in Ontario?

Can an Insurer Cut Off Your Accident Benefits Claim for Missing a Medical Exam?

Yes — under Ontario’s Statutory Accident Benefits Schedule, refusing to attend a properly requested insurer examination can bar your entire claim before it ever reaches a hearing. That is exactly what happened in Yousif v The Personal Insurance Company, 2026 CanLII 115048 (ON LAT), a preliminary issue decision released October 29, 2026. The Licence Appeal Tribunal dismissed the application on two separate grounds, neither of which touched the underlying question of whether the claimant was actually catastrophically impaired.

If you have been injured in a crash and are pursuing accident benefits — especially a catastrophic impairment designation — understanding these procedural rules is as important as the medical evidence itself.

What Is an Insurer Examination and When Can an Insurer Require One?

An insurer examination (IE) is a medical or vocational assessment arranged by the insurance company at its own expense to help determine whether a claimant is entitled to a benefit. Section 44 of the Schedule allows an insurer to require these assessments, but only as often as is reasonably necessary given the issues in dispute.

In this case, the claimant had submitted a first catastrophic impairment application in 2023 alleging impairment under two criteria. The insurer arranged assessments at that time and concluded the threshold was not met. The claimant then submitted a second application in 2025 that added a third criterion — one that had never been assessed before — and relied on reports showing substantially higher impairment ratings than those obtained in 2023. The Tribunal found that these developments gave the insurer a reasonable basis to schedule new examinations covering the new criterion and the significantly different findings.

What Happens If You Refuse to Attend an Insurer Examination?

Refusing to attend a properly requested and properly noticed insurer examination bars you from proceeding to a hearing at the Tribunal. Section 55(1)2 of the Schedule makes this explicit: if an insurer has given valid notice of an examination and the claimant has not complied, the claimant cannot apply to the Tribunal. The Tribunal has a discretion under s. 55(2) to let the application proceed despite non-compliance. Here it declined, because there was no compelling explanation for the non-attendance and the insurer would be prejudiced in its ability to investigate and determine entitlement, including a newly asserted criterion that had not previously been assessed.

In this decision, the claimant’s legal representative advised the insurer that the claimant simply would not attend. The Tribunal found no medical evidence showing the claimant was unable to attend. After the missed appointments, the insurer’s letters of October 15 and October 24, 2025 advised the claimant to contact the adjuster to reschedule the examinations, showing the insurer remained willing to proceed if the claimant agreed to attend. Disagreeing with the insurer’s right to request an examination is not, on its own, a valid reason to refuse. The Tribunal declined to exercise its discretion to allow the claim to continue.

What Must an Insurer’s Notice of Examination Include?

For an insurer examination to be validly required, the notice must meet specific requirements under s. 44(5) of the Schedule. It must identify the assessors and their professional qualifications, state the dates, times, and locations of the examinations, and explain the medical and other reasons why the assessments are needed.

The insurer’s August 2025 notices in this case named each assessor, their profession, and the scheduled appointment details. They also explained that the insurer could not determine whether the claimant had sustained a catastrophic impairment, identified a significant gap between the 2023 insurer findings and the 2025 claimant reports, noted that a new criterion was now being claimed, and stated that additional opinions were needed. The Tribunal found this was detailed enough for the claimant to understand both what was being assessed and why. Notices that are vague or fail to explain the reasons for the examination may not meet this standard.

When Does the Two-Year Limitation Period Start for Accident Benefits?

The two-year limitation period under s. 56 of the Schedule begins to run from the date the insurer refuses to pay a benefit or a portion of a benefit. The Tribunal applied the test from Smith v. Co-operators General Insurance Co., 2002 SCC 30: a refusal must be conveyed in clear, straightforward language that an unsophisticated person can understand, and it must give enough information about the dispute-resolution process and the relevant time limits.

In this case, a treatment plan for catastrophic impairment assessments was submitted in December 2022. The insurer responded on December 23, 2022, approving some expenses and expressly declining to fund others, with reasons tied to maximum rates under the Schedule. The insurer approved $4,690 on that date and later paid $16,690 toward the expenses. The Tribunal held that the later payment did not undo the clear partial refusal of the $20,800 balance. The claimant did not commence the Tribunal application until January 3, 2026 — more than two years later. The claim for that unpaid balance was therefore statute-barred.

Can the Tribunal Extend the Limitation Period?

The Tribunal has jurisdiction under s. 7 of the Licence Appeal Tribunal Act, 1999 to extend a limitation period where reasonable grounds are shown. However, the claimant must put forward specific submissions explaining why an extension is justified. In this case, the claimant relied on s. 7 as an alternative argument but did not provide the Tribunal with specific reasons or circumstances supporting an extension. Without that, the Tribunal was not persuaded that relief was warranted.

This is an important reminder: if you think you may have missed a deadline, simply raising the possibility of an extension is not enough. You need to explain why the justice of the situation calls for one.

Questions and Records to Discuss with a Lawyer

If you are involved in an accident benefits dispute in Ontario, the following points may be worth exploring with legal counsel:

• Have you received any letters from your insurer partially approving or reducing a treatment plan, and if so, when were those letters sent?
• Have you received a Notice of Examination from your insurer, and do you understand what it is asking you to do and by when?
• If you have already submitted one catastrophic impairment application, are you aware that a second application raising new criteria or new evidence may trigger additional insurer examinations?
• Are there any gaps between the dates of insurer correspondence and the date you first contacted a lawyer or the Tribunal?
• Do you have documentation of any medical reasons that may have affected your ability to attend scheduled assessments?

Our Ontario motor vehicle accident lawyers work with clients navigating accident benefits disputes, including catastrophic impairment claims. If you have questions about your own situation, you are welcome to reach out through /connect to discuss the details with our team.

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This article is automated commentary on a public court decision and is for general information only — not legal advice. Decisions rely on facts unique to each case. If you are affected by a similar issue, contact a lawyer for advice specific to your situation.