When Can an Insurer Deny Accident Benefit Treatment Plans in Ontario?

What Does ‘Reasonable and Necessary’ Mean for Accident Benefit Treatment Plans?

In Ontario, an insurer must pay for a treatment plan only if the proposed services are both reasonable and necessary as a result of the accident. That standard, set out in the Statutory Accident Benefits Schedule, means more than proving you were hurt — you must show that the specific treatment proposed is likely to help you, given your current condition and treatment history. This is the central question examined in Wong v Allstate Insurance Company of Canada, 2026 ONLAT 25-007444/AABS (CanLII), a decision released October 6, 2026 by the Licence Appeal Tribunal.

The applicant was injured in a motor vehicle collision in January 2021 and later sought funding for physiotherapy, occupational therapy, psychological services, and a multidisciplinary catastrophic impairment assessment. Allstate denied all four plans. The Tribunal agreed with the insurer on every issue.

Does Ongoing Pain Automatically Entitle You to More Treatment?

Ongoing pain does not automatically entitle an accident victim to further treatment funding under Ontario’s accident benefits system. The Tribunal was clear: the question is not whether you still have symptoms, but whether the particular plan proposed is likely to produce a meaningful benefit.

In this case, the applicant had received extensive physiotherapy and psychotherapy following the collision. Treatment records from one clinic repeatedly noted that the applicant felt “the same” after sessions, and later progress reports from both clinics did not convincingly document objective improvement. A physical medicine and rehabilitation specialist whose assessments the insurer relied on examined the applicant in 2021 and again in January 2024, and found no structural or physiological abnormality requiring ongoing formal treatment. The Tribunal gave that expert’s opinion significant weight because it was grounded in in-person physical examinations with detailed objective findings.

Can a Statement About Recovery Be Used Against You in an Accident Benefits Claim?

Yes — a claimant’s own statements to a medical assessor can be used to challenge later claims for treatment. During a psychological assessment in May 2022, the applicant told the assessing psychologist that her accident-related pain had resolved. The Tribunal found that statement difficult to reconcile with the argument that extensive physical rehabilitation was still required more than a year after that report, and no persuasive medical evidence explained any subsequent deterioration tied to the January 2021 accident.

This is a practical reminder that statements made to medical assessors can become part of the evidence in a later dispute.

What Evidence Do You Need to Fund a Catastrophic Impairment Assessment?

To obtain funding for a CAT assessment, you must show a reasonable evidentiary basis for investigating whether you may meet a catastrophic impairment criterion — not prove catastrophic impairment outright. However, the evidence must also support the specific assessments proposed, not just the idea that some assessment may be warranted.

Here, the Tribunal found that while the applicant’s psychological diagnosis (Adjustment Disorder with Mixed Anxiety and Depressed Mood) raised a closer question, the plan as a whole was not adequately supported. The applicant did not explain why a full multidisciplinary package — including physiatry, occupational therapy, psychology assessments, three separate file reviews, and an overall rating — was required given the available medical evidence. The Tribunal also found that the three proposed file-review charges appeared to duplicate work that would ordinarily be part of the primary assessments, making those additional charges unreasonable.

Our Ontario accident benefits lawyers regularly advise clients on what supporting evidence is needed before submitting a CAT assessment plan.

Can an Insurer Bar You from the Tribunal for Missing an Independent Medical Exam?

An insurer cannot automatically bar you from the Tribunal simply because you missed a scheduled independent medical examination (IME). Section 55(1)2 of the Schedule does bar a claimant who fails to comply with a s. 44 examination requirement — but the Tribunal found that bar did not apply here.

The applicant had notified Allstate in advance that she was unavailable on the scheduled date and asked for a new appointment. Allstate produced no evidence that it attempted to reschedule. Because the applicant gave prior notice and requested an alternative date, the Tribunal was not satisfied that her non-attendance amounted to a failure to comply with the examination requirement. The insurer bore the burden of proving non-compliance, and on these facts it did not meet that burden.

How Does Prior Treatment History Affect Future Benefit Claims?

Prior treatment history is directly relevant to whether a new treatment plan is reasonable and necessary. The Tribunal relied on an earlier LAT decision to confirm that the outcomes of previous treatment are a legitimate factor when assessing whether a proposed continuation of that treatment is likely to work.

Where a claimant has undergone many sessions of physiotherapy or psychotherapy and the records show little measurable improvement, an insurer can argue — and a tribunal can accept — that another substantially similar block of sessions is unlikely to achieve the stated goals. Applicants and their treatment providers should document functional gains clearly and specifically, not just ongoing symptoms.

If you have been injured in a collision and are navigating the accident benefits process, our motor vehicle accident lawyers can help you understand what evidence supports your claims.

Questions and Records to Discuss with a Lawyer

• What do your treatment progress notes actually say about measurable functional improvement, and how clearly do they link ongoing impairments to the specific accident at issue?
• Have you made any statements to an insurer’s assessor about your recovery or pain levels that might be inconsistent with a current treatment plan?
• If you missed an insurer’s examination, did you give advance notice and request a new date, and is there a written record of that request?
• Does your proposed CAT assessment plan explain why each individual component is required, and does it address whether any proposed services overlap with one another?
• Are your ongoing psychological symptoms clearly attributed to the accident in question, particularly if you were involved in more than one collision?

If you have questions about your own accident benefits situation, you are welcome to reach out to UL Lawyers through our contact page to discuss your circumstances.

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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.