Accident benefits denied in Ontario does not necessarily end the claim. The reason may involve a treatment plan, evidence, eligibility or optional coverage, and disputes are generally addressed through the accident-benefits process and, where applicable, the Licence Appeal Tribunal. This guide explains practical next steps.
Key takeaways: Keep the denial letter, identify the disputed benefit, gather medical and treatment records, and check the applicable dispute deadlines before responding.
Accident benefits are no-fault
Ontario’s accident benefits system is “no-fault”. You claim benefits from your own auto insurer (or another applicable insurer), even if another driver was entirely to blame. Fault does not decide whether you receive accident benefits.
Accident benefits are also not compensation for pain and suffering. They fund specific needs, especially care and treatment that OHIP generally does not cover, such as physiotherapy, massage therapy, occupational therapy, psychological treatment, chiropractic care, personal support workers and assistive devices. Compensation for pain and suffering is pursued separately, through a tort claim against the at-fault party.
Common reasons for a denial
Insurers deny or limit benefits for many reasons. Common ones include:
• Not reasonable and necessary. The insurer decides that a treatment plan is not reasonable and necessary, often after an insurer examination or a paper review.
• Minor injury. The insurer places the injuries within the Minor Injury Guideline, which has a lower funding limit.
• Missing information or late forms. Forms, records or examinations were not provided or attended.
• Eligibility. The insurer says the incident was not an “accident” under the SABS, or that the person is not an insured person.
• Coverage. Since July 1, 2026, many benefits are optional. A claim for income replacement, non-earner, caregiver or other optional benefits may be denied because the policy does not include that coverage.
• Limits reached. The available benefit limit has been used up.
The reason matters, because it shapes the response. A coverage-based denial raises different questions, such as which policy applies, what was bought and whether renewal documents changed it, than a dispute about whether treatment is reasonable and necessary.
What to do after a denial
1. Keep the denial letter and every related document. Note the date you received it.
2. Read the reasons carefully. Insurers are generally required to explain why benefits are denied.
3. Ask for the insurer’s reports. If the denial relies on an insurer examination or paper review, ask for a copy.
4. Talk to your treatment providers. A revised plan or further medical evidence may address the insurer’s concerns.
5. Check your policy, especially for optional benefits after July 2026.
6. Act promptly. Strict time limits apply to disputing a denial.
7. Consider getting legal advice before deciding whether to dispute.
Where disputes are decided: the Licence Appeal Tribunal
In general, you cannot sue your own insurer in court over a denial of accident benefits. Disputes are decided by the Licence Appeal Tribunal (LAT), part of Tribunals Ontario. Some features of the LAT process:
• Cases are decided by adjudicators, not judges.
• The focus is entitlement to benefits under the SABS, not who caused the accident.
• There may be preliminary issues to resolve, such as whether the incident was an “accident” or which insurer should pay, before the benefits themselves are considered.
• The process usually includes case conferences and, if the dispute is not resolved, a hearing (often in writing or by video).
An application to the LAT should be filed within the applicable two-year period after the insurer’s refusal. See Insurance Act, s. 281.1(1), SABS s. 56, and https://www.thomsonrogers.com/blog/right-to-claim-catastrophic-attendant-care-and-housekeeping-benefits-returned/.
Is a dispute worth it?
Whether to dispute is a practical as well as a legal decision. For a single, modest treatment plan, the time and cost of a contested dispute can sometimes be more than the amount in issue. For ongoing benefits, catastrophic impairment claims or income-related benefits, much more may be at stake. Factors to weigh include how strong the medical evidence is, the total value of the benefits in issue, and how the dispute fits with any tort claim.
What about bad faith?
Insurers must handle claims in good faith. Damages for bad faith against an accident benefits insurer are, however, rare and difficult to obtain, and the forum and remedies available are limited. A denial you disagree with is not, on its own, bad faith. Any such concern should be reviewed by a lawyer on the specific facts.
Accident benefits and your tort claim
If someone else caused the accident, you may also have a claim against them for pain and suffering, lost income and future care. That claim is separate from accident benefits. Benefits you received, or could have received, can affect how damages are calculated in the lawsuit. Early, coordinated advice can help with both.
Insurer examinations and paper reviews
Many denials follow an insurer examination, where a health professional chosen by the insurer assesses you, or a paper review, where that professional reviews your records without meeting you. These reports can carry significant weight. If you are asked to attend an examination, go, unless there is a genuine reason you cannot. In that case, tell the insurer promptly and in writing. Not attending without a reasonable explanation can itself lead to benefits being suspended or denied.
Before and after an examination, it can help to:
• describe your symptoms and limitations honestly and completely, including good days and bad days;
• write down how long the examination lasted and what was done;
• ask for a copy of the report once it is available; and
• share the report with your own providers, who may be able to respond to it with their own opinions.
A difference of opinion between the insurer’s assessor and your own treating providers is common. It is often the central issue in a dispute about whether treatment is reasonable and necessary.
Conclusion
If accident benefits are denied in Ontario, organize the denial and supporting records promptly. Contact Booni Law at admin@boonilaw.com or +1 (226) 271-1751 to discuss the available process. No outcome is promised.
Frequently Asked Questions
Can I sue my insurance company for denying my accident benefits?
Generally, no. Accident benefits disputes are decided by the Licence Appeal Tribunal rather than the courts.
How long do I have to dispute a denial?
The generally applicable period is two years after the insurer’s refusal. See Insurance Act, s. 281.1(1), SABS s. 56, and https://www.thomsonrogers.com/blog/right-to-claim-catastrophic-attendant-care-and-housekeeping-benefits-returned/.
Does the LAT decide who caused the accident?
No. The LAT decides entitlement to accident benefits. Fault is relevant to a separate tort claim.
My income replacement claim was denied after July 2026. Why?
Income replacement became an optional benefit on July 1, 2026. The denial may be coverage-based. Check the applicable policy and endorsements.
Can I submit a new treatment plan after a denial?
Often, yes. Your provider may be able to submit a revised plan with more supporting evidence. Keep the earlier denial in mind, because disputing it may still matter.
Had your accident benefits denied?
If your accident benefits or a treatment plan have been denied, Booni Law can review the denial and explain the options that may be available. Email Booni Law at admin@boonilaw.com or call +1 (226) 271-1751 to discuss your situation. Time limits may apply, so it is best to reach out promptly.
Disclaimer: This article is provided for general informational purposes only and does not constitute legal advice. Reading this article does not create a solicitor-client relationship between you and Booni Law. The information in this article may not reflect the most current legal developments and should not be relied upon as a substitute for professional legal advice tailored to your specific circumstances. If you require legal advice, please contact Booni Law.
