Category: Income Replacement Benefits

Coban v. Allstate Insurance Company (2026 ONSC 1925)

The claimant appealed the Tribunal’s decision that he was not entitled to IRBs because he was receiving WSIB at the time of the accident rather than income from an employer. The Court allowed the appeal, holding that the claimant was an employed person at the time of the accident, even though he was not receiving income directly from his employer. The claimant was participating in a retraining program through his employer and WSIB, and intended to return to work, had the car accident not occurred. The Court reasoned that the Tribunal’s interpretation of the term “employed” was too narrow and defeated the consumer protection nature of the SABS.

Mensah v Co-operators General Insurance Company (24-014094)

The claimant was involved in an automobile accident in February 2022. She applied to the LAT seeking CAT determination under Criterion 8 and entitlement to IRBs, ACBs, and numerous medical benefits. The claimant brought a motion to exclude the surveillance evidence because the respondent did not comply with the case conference order to disclose the investigator’s handwritten notes, the surveillance agreement between the respondent and the investigation company, all communications between the investigator and the respondent, invoices, and unredacted adjuster log notes that relate to surveillance. The LAT found that the surveillance evidence was admissible because of the probative nature of the evidence. The LAT found that the claimant was not CAT and not entitled to the majority of the issues in dispute.

Hou v Aviva General Insurance Company (25-000946)

The claimant was involved in an automobile accident in August 2023. He applied to the LAT to dispute IRB quantum and entitlement to medical benefits and a special award. The LAT found that the IRB quantum calculated by the insurer was correct as it was based on the self-employed claimant’s income in the last fiscal year. The LAT found that IRBs were not payable for the period prior to submission of an OCF-3, and also not payable for the period in which the claimant failed to comply with s. 33 requests for documents that were reasonably required to assess entitlement to IRBs. S. 33 suspensions of benefits were not upheld for periods related to requests that were not considered reasonable. The claimant was found to be entitled to part of the balance of an OCF-18 that was partially approved up to the MIG limits, but the LAT found that the amount proposed for a re-assessment was not reasonable and necessary. The LAT found that the claimant was entitled to a special award as the insurer unreasonably delayed approval and payment of IRBs

Traders General Insurance Company v. Rumball (2025 ONSC 656)

The claimant appealed the Divisional Court’s decision that upheld the denial of post-104 IRBs. She argued that the Court and Tribunal failed to apply the proper test. In particular, the claimant argued that the Court failed to consider whether suitable employment existed in a real-world setting, and in putting the onus on her to prove her inability to work. The Court dismissed the appeal, holding that the post-104 IRB test required an evidence-based, contextual analysis. Factors such as competitive, real-world setting, status, and remuneration of alternative employment were relevant, but were not stand-alone requirements. The Court also held that the onus was on the insured to prove her entitlement to post-104 week IRBs.

Gutierrez v. Security National Insurance Company (2025 ONSC 5174)

The claimant sought judicial review of the LAT’s decision that he was not entitled to IRBs, and the LAT’s refusal to add the claim for pain and suffering. The Divisional Court dismissed the judicial review, holding that the Tribunal considered the evidence before it when adjudicating the IRB claim, and that the Tribunal reasonably declined to add a claim for pain and suffering.

Park v. GEICO Insurance Company (2025 ONSC 4282)

The claimant appealed the Tribunal’s decision that he was not entitled to IRBs. The Court dismissed the appeal, holding that the claimant received a fair hearing, and that the alleged uneasonableness in factual and evidentiary findings was not proven. The record showed no unreasonableness in the Tribunal’s findings or inferences drawn from the findings.

Derenzis v. Gore Mutual Insurance Co. (2025 ONSC 2732)

The claimant appealed the Tribunal’s decision that she was not entitled to IRBs due to IE non-attendance. The Court dismissed the appeal, concluding that the Tribunal did not make an error. The Court found that the IE notices were adequate, and that the Tribunal was entitled to consider the cumulative effect of the prior IE notices in determining compliance. The Court also rejected the arguments made by the claimant regarding the Tribunal lacking impartiality.

Gordan v Certas Direct (22-011660)

The claimant was involved in an automobile accident in October 2020. She applied to the LAT seeking CAT determination under Criterion 8 and entitlement to IRBs. The LAT denied the claimant’s request to rely on a late-filed supplementary hearing brief as the prejudice to the respondent outweighed the probative value of the documents. The LAT found that the claimant was CAT under Criterion 8 due to marked impairments in three spheres of function, including Adaptation. Despite the CAT determination, the LAT found that the claimant was not entitled to post-104 IRBs. The LAT confirmed that applicants bear the burden of proving they meet the test and criteria for benefits, and the claimant failed to demonstrate entitlement to post-104 IRBs, in part due to her failure to tender expert opinion evidence addressing post-104 IRBs. In contrast, the insurer tendered expert opinion evidence on post-104 IRBs, which the LAT relied on for its decision.

Jendrika v. Intact Insurance Company (2025 ONSC 652)

The claimant appealed the Tribunal’s decision that she was not entitled to IRBs or disputed medical benefits. The Court dismissed the appeal, holding that there was no procedural unfairness in conducting a written hearing, and that the claimant’s appeal was largely based on disagreement on the weight to be given to the evidence and expert opinions. Neither party made submissions regarding the MIG, so the adjudicator was entitled to conclude that it was not an issue in dispute. Finally, the Tribunal applied the correct test for pre-104 week and post-104 week IRBs.

Bailey v Traders General Insurance Company (24-003141)

The claimant was involved in an automobile accident in July 2020. She applied to the LAT seeking entitlement to IRBs and medical benefits. With regards to IRBs, the parties disagreed over the period when the “complete inability” standard comes into effect. The claimant argued that the wording “104 weeks of disability” means that this standard does not apply until an insured person has had a cumulative period of 104 weeks at the “substantial inability” standard. Since the applicant returned to her pre-accident role for a period following the accident, she argued that the nine-week period at issue remained within “the first 104 weeks of disability”. As such, the “substantial inability” standard would apply. The respondent disagreed, arguing that the stricter standard comes into effect once 104 weeks have elapsed since the accident. The LAT agreed with the respondent and found that the “complete inability” standard comes into effect 104 weeks after the accident.

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