Licence Appeal Tribunal seeks to deter insurers from conditionally approving accident benefits
In a proceeding in which an injured applicant could not access accident benefits from the respondent insurance company, the Ontario Licence Appeal Tribunal awarded him 10 percent of the benefits claimed due to the insurer’s unfair conduct.
The case was Zondervan v Definity Insurance Company, 2026 CanLII 97276 (ON LAT). On Mar. 8, 2023, the then-16-year-old applicant was trying to cross a street when the ION light rail train operating in the Waterloo region struck and pinned him.
The applicant sustained multiple injuries, including hip, leg, and rib fractures. He lost consciousness. After his transfer to the hospital, he needed intubation, numerous surgeries, and a long stay.
The applicant sought benefits from the respondent insurer under the Statutory Accident Benefits Schedule – Effective September 1, 2021 (including amendments effective June 1, 2016) (SABS).
The insurer agreed to pay benefits if the benefits were incurred and if its appeal failed.
While not disputing the severity of injuries, the insurer denied the applicant’s involvement in an accident under the SABS, which required the use or operation of an automobile. The insurer alleged that the train was not an automobile.
In a preliminary issue decision dated Oct. 6, 2025, the Licence Appeal Tribunal determined that the applicant indeed had an accident.
The insurer requested a reconsideration. The tribunal rejected the request as premature.
On Oct. 28, 2025, without seeking a judicial review or a stay, the insurer appealed against the preliminary issue decision before the Divisional Court.
The Licence Appeal Tribunal found the applicant entitled to the following from the insurer:
The Licence Appeal Tribunal saw no need for a reasonable and necessary analysis in this case. According to the tribunal, the insurer confirmed that the benefits were reasonable and necessary due to the accident, given its approval of the disputed benefits.
The Licence Appeal Tribunal capped the award against the insurer at 10 percent to strike a balance between the applicant’s entitlement to and need for benefits and the insurer’s appeal rights.
The tribunal held that the award would discourage the insurer from:
The tribunal added that the award would deter other insurers from acting similarly in the future.
Given the ongoing refusal without basis to pay the applicant benefits, the tribunal ruled that the insurer acted in an imprudent, stubborn, inflexible, unyielding, or immoderate manner after the preliminary issue decision.
The tribunal described this case as an example of how a conditional approval of benefits amounted to an ongoing denial of benefits.
The tribunal explained that the conditional offer left the applicant in the vulnerable position of not knowing whether he could access benefits incurred because of the accident.
Here are some other recent injury-related decisions by the Ontario Licence Appeal Tribunal.
On Aug. 12, the tribunal did not find a man injured during a carjacking entitled to the benefits he claimed because the incident was not an accident as defined in s. 3(1) of the SABS.
On Aug. 4, the tribunal determined that an incident involving an all-terrain vehicle that crashed into a tree and caused traumatic brain injury to the driver was an accident under s. 3(1) of the SABS.
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