Wawanesa defeats accident benefits bid over minor injury guideline evidence gap

A two-and-a-half-year silence in the medical file is what really undid this MIG challenge

Wawanesa Mutual Insurance Company has kept an accident-benefits claimant inside the $3,500 minor injury cap, defeating a bid built on knee pain and anxiety. An Ontario Licence Appeal Tribunal adjudicator ruled on June 30, 2026 that the claimant's injuries fell within the Minor Injury Guideline (MIG), the ceiling that limits medical and rehabilitation benefits to $3,500 for predominantly minor injuries. The decision upholds the insurer's denial of two disputed treatment plans and rejects her claims for interest and a special award.

The dispute arose from a December 8, 2022 automobile accident. The claimant, a personal support worker, reported pain in her left wrist, both knees and left hip. She argued she should be removed from the MIG on three grounds: a pre-existing knee injury, a psychological condition, and chronic pain.

Each argument failed on the evidence. On the pre-existing condition, the adjudicator accepted that the claimant had documented knee trouble before the crash - she had seen her family physician in October and November 2022 after falling from her bicycle. But under section 18(2) of the Statutory Accident Benefits Schedule, a documented condition alone is not enough.

The claimant also needed compelling medical evidence that the condition would preclude recovery within the MIG. That evidence was absent. The psychological claim drew the sharpest evidentiary contrast.

The claimant relied on a section 25 pre-screen report that offered no testing, diagnosis or recommendation beyond suggesting an assessment, plus a single-paragraph letter from a psychiatrist abroad. The adjudicator assigned the letter less weight, noting it came with no clinical records, no test results and no indication the conditions were caused by the accident. Wawanesa, by contrast, relied on a review of family-physician records and a section 44 insurer's examination.

The examining psychologist ran a battery of tests - including the Beck Anxiety Inventory and a malingering screen - and found no DSM-5 psychological condition. The adjudicator gave that report more weight because it clearly set out its methodology, and because it aligned with the family physician's notes, which recorded no psychological complaints after the accident. The chronic pain argument was undone by a treatment gap.

The claimant did not return to her family physician for knee pain until April 29, 2025 - nearly two and a half years after the accident. That silence, the adjudicator found, showed the pain was not significant enough to warrant ongoing care. Diagnostic imaging showed "moderate patellar tendinopathy and small effusion" - swelling, not a tear, in the adjudicator's plain-language reading - and did not merit removal from the MIG.

With the claimant held to the MIG, the adjudicator declined to assess whether the two treatment plans - $318.19 for imaging and $2,200 for a psychological assessment - were reasonable and necessary. The insurer also escaped a special award under section 10 of Regulation 664, which lets the Tribunal order up to 50 per cent of the total benefits payable where an insurer unreasonably withholds or delays payment. The adjudicator found no benefits were unreasonably withheld or delayed, so no award was payable.

With no benefits overdue, no interest was payable either. The application was dismissed.