Licence Appeal Tribunal File Number: 25-000241/AABS
In the matter of an application pursuant to subsection 280(2) of the Insurance Act, RSO 1990, c I.8, in relation to statutory accident benefits.
Between:
Antonio Mete
Applicant
and
Allstate Insurance Company of Canada
Respondent
DECISION
VICE-CHAIR:
Neil Levine
APPEARANCES:
For the Applicant:
Piera A. Segreto, Counsel
For the Respondent:
Jonathan White, Counsel
Court Reporter:
Diana Persaud
HEARD by Videoconference:
October 28 and 29, 2025
OVERVIEW
1Antonio Mete, the applicant, was involved in an automobile accident on June 20, 2024, and sought benefits pursuant to the Statutory Accident Benefits Schedule - Effective September 1, 2010 (including amendments effective June 1, 2016) (the “Schedule”). The applicant was denied benefits by the respondent, Allstate Insurance Company of Canada, and applied to the Licence Appeal Tribunal - Automobile Accident Benefits Service (the “Tribunal”) for resolution of the dispute.
ISSUES
2The issues in dispute are:
i. Is the applicant entitled to an income replacement benefit in the amount of $400.00 per week from June 17, 2025 ongoing? Note: the applicant was paid an IRB from one week post-accident to June 17, 2025.
ii. Is the respondent liable to pay an award under s. 10 of Reg. 664 because it unreasonably withheld or delayed payments to the applicant?
iii. Is the applicant entitled to interest on any overdue payment of benefits?
iv. Is the applicant entitled to costs pursuant to Rule 19?
3Withdrawn Issue: The applicant withdrew item 4(2) (emergency services expenses) from the case conference report and order at the hearing.
RESULTS
4I find that:
i. The applicant is entitled to an income replacement benefit in the amount of $400.00 per week from June 17, 2025 ongoing.
ii. The applicant is entitled to an award of $2,280.00 under s. 10 of Reg. 664 because the respondent unreasonably withheld or delayed payments to the applicant.
iii. The applicant is entitled to interest in accordance with s. 51 of the Schedule.
iv. The applicant is not entitled to costs.
PROCEDURAL ISSUES
Updated Applicant Submissions
5At the beginning of the hearing the applicant sought to submit a revised submission document that included a new disability certificate (OCF-3) provided by the applicant’s family doctor in the days preceding the hearing.
6The respondent sought to exclude this certificate as it was late filed according to the rules for productions stipulated in the case conference report and order of May 6, 2025 which ordered a document exchange no later than 30 days from the case conference. The respondent argued that this document should be excluded because its inclusion would not allow the respondent time to review it.
7The applicant asked that this document be permitted because it is an updated rather than new certificate, and the records that are attached to it were previously seen by the respondent.
8Rule 9.3 of the LAT Rules 2023 (the “Rules”) states that a party who fails to comply with an order with respect to disclosure, exchange or production of a document, is not permitted to rely on the document as evidence, without the Tribunal’s permission. When considering the relevant factors in Rule 9.3 for determining whether to grant such permission, I do not find that the respondent is prejudiced by the admittance of this document and records because it is not a new but rather an updated document, and records attached to it were already seen by the respondent as part of the document and production exchange well before the new OCF-3 was received. I will allow them to be admitted as evidence at this hearing because they are relevant to the issues in dispute (Rule 9.3) and I am not persuaded of any prejudice to the respondent.
ANALYSIS
Income Replacement Benefits
9The applicant is entitled to the income replacement benefit claimed, from June 17, 2025 ongoing.
10To receive payment for an IRB under s. 5(1) of the Schedule, the applicant must be employed at the time of the accident and, as a result of and within 104 weeks after the accident, suffer a substantial inability to perform the essential tasks of that employment. The applicant must identify the essential tasks of their employment, which tasks they are unable to perform and to what extent they are unable to perform them. The applicant bears the burden of proving, on a balance of probabilities, that they meet the test.
11The analysis of IRB eligibility consists of one part that is relevant in this case: Does the applicant suffer a substantial inability to perform the essential tasks of his employment as a result of the accident?
12The applicant was employed at ACA Group in the warehouse. His job responsibilities and essential tasks and duties included health and safety, loading and unloading, receiving and shipping deliveries, and preparing equipment. Based on the testimony of the applicant and the applicant’s supervisor, the size of boxes and equipment he handled was from smaller boxes to those of 90 pounds or more. He used a pump truck to move, push or pull skids of 200-300 pounds or more. For example, photos were shown of boxes that were 165kg and as large as 606 lbs/275 kg. Most of the applicant’s work involved lifting, carrying and filling orders, that is, physical rather than sedentary work.
13The applicant was driving on June 20, 2024 and swerved to avoid hitting a fox on the road. The applicant hit a light standard. He did not lose consciousness. He visited his family doctor, Dr. John Zasowski, a few days after the accident and he provided his employer with a note from this doctor stating that he was unable to work. He was referred for physiotherapy and an OCF-1 was submitted on July 2, 2024. He attempted to return to work from July 29, 2024 until August 22, 2024 whereupon on the latter date he was terminated by his employer. The applicant believes he was terminated because he was unable to complete his work duties.
14The symptoms the applicant testified to at the first visit to his doctor and subsequent visits included soreness, headaches, right knee pain and back pain. These symptoms were corroborated in the applicant’s family doctor’s records. For example, his family doctor’s records from July 29, 2024 noted soreness and headaches, but despite these symptoms, he felt pressure to return to work. It was also noted that the applicant’s psychological assessment from September 2024 stated that he suffered from emotional and psychological problems that were consistent with adjustment disorder as a result of the accident.
15The applicant was involved in a second accident on August 24, 2024. It is the contention of the applicant that the respondent conflated the two accidents and this affected the efficient and professional handling of the applicant’s file and specifically his ability to obtain income replacement benefits.
16The applicant’s OCF-3 for the subject accident was completed on September 12, 2024, apparently due to delays on the part of the applicant’s family doctor. The applicant’s employer did not or would not provide a confirmation of income and the applicant could not access his pay stubs so the respondent was provided with copies of bank statements from a year prior to the accident. There were also two medical notes in the applicant’s file with the respondent that indicated the applicant was not able to return to work in June and July 2024, save for the three week period between June 29, 2024 and August 22, 2024.
17The applicant was paid IRB from August 29, 2024 to June 17, 2025 whereupon the respondent terminated the IRB based on s. 44 assessments. The respondent submits that the applicant has no injuries that satisfy the test for IRB entitlement under s. 5(1), and that the applicant failed to provide pay stubs or an employment file as required. The respondent also maintains that the applicant’s file was handled fairly.
18After the accident and visiting Dr. Zasowski, the applicant attended to physiotherapy, and an OCF-1 dated December 13, 2024 notes that his injuries from the first (subject) accident prevented him from working. As well, the OCF-3 from Dr. Zasowski, dated September 11, 2024 noted headaches, chest tenderness, knee pain and back pain and said that the applicant was substantially unable to perform his work duties.
19In terms of the medical evidence supporting accident-related injuries, clinical notes and records from Dr. Kamilia Nastasi and Dr. Muriel Lilly at walk-in visits on June 21, 2024 (the day following the accident) and July 4, 2024 note that the applicant was prescribed medications diclofenac (an anti-inflammatory drug), cyclobenzaprine and naproxen for his pain. While the respondent asserted that some of these prescriptions were never filled, I still find it persuasive that the applicant’s treating doctors were of the view that the applicant suffered from injuries sufficient to warrant the prescription of pain medication.
20Clinical notes and records from physiotherapists and chiropractors at Full Function Rehab were submitted by the applicant. These CNRs document twice-weekly visits to this clinic to treat the applicant’s pain in his upper back, neck and shoulders and right knee and numbness in left hand, from September 17, 2024 through August 2025. This is a consistent record of the applicant’s medical issues and treatment for them.
21The respondent also referred to instances (noted in CNRs) in which the applicant was working in the yard at his parents and lifted a 20 pound bag of material and stone more than once, and shovelled snow while playing with his children. While these isolated occurrences may point to some measure of the functionality, as previously noted above, the applicant’s job tasks involved handline boxes of 90 pounds or more. In my view, the examples cited by the respondent do not show how the applicant would have been able to work at his job.
22The applicant was assessed by Dr. Saad Naaman, a physiatrist on May 16, 2025 and an IE report was issued on June 10, 2025. I place less weight on this assessment because the records of Dr. Naaman show that he was only given an OCF-1 related to the August accident but not the applicant’s June subject accident, nor was he provided with CNRs from the June subject accident. Furthermore, this assessment was almost one year after the subject accident. In addition, the applicant noted that he was assessed in person with Dr. Naaman for only 15 minutes, and the applicant’s knee ultrasound was not reviewed, despite CNRs from Full Function Rehab consistently noting on a weekly basis from September 2024 through August 2025 that the applicant suffered from ongoing knee pain, upper back pain, neck and shoulder pain, and numbness in his right hand. I further note that there are inconsistencies in the report about the prescription medicines the applicant was reported to be taking and the number of times per week the applicant may or may not have gone to the gym.
23Dr. Naaman’s s. 44 examination did note that the applicant suffered from significant right knee pain that meant he was unable to stand and perform essential work duties for more than ten or 15 minutes. Yet, despite noting the applicant’s inability to stand and perform work duties for more than ten or 15 minutes, Dr. Naaman found no impairments from the applicant’s injuries.
Psychological
24The applicant was also assessed by the psychologist Dr. Sadet Yilmaz, whose s. 25 report dated November 1, 2024 said the applicant suffered from emotional and psychological problems consistent with adjustment disorder, with mixed anxiety and depressed mood. In this assessment the applicant also noted his physical pain and discomfort. The applicant also visited Dr. Monique Costa El-Hage for a section 44 psychological assessment which noted these same issues but nevertheless concluded that the applicant was able to work.
25I place less weight on the s. 44 assessment of Dr. Costa El-Hage who asserted that the applicant suffered from anxiety before the accident, related to his divorce and child custody issues, and that it was only slightly exacerbated by the accident. I place less weight on this evidence because the assessor appeared less familiar with the applicant’s actual circumstances, for example, though he was not on modified duty at work the assessor seemed to think that he was.
26Furthermore, this report is less credible because the assessor describes a long list of psychological and psychosocial behaviours problems that the applicant experiences such as depression, anxiety and a “cry for help” (she diagnosed adjustment disorder with mixed anxiety and depressed mood) but still concludes that any problems are attributable mostly to his separation from his wife and children. The assessor concludes he therefore has no psychological issues that would prevent him from returning to work while most other evidence says the opposite.
Termination of Employment
27The applicant was employed up to and during his subject accident. He attempted to return to work from July 29, 2024 until August 22, 2024 and then was terminated. On a balance of probabilities and based on the evidence and testimony, I find that he was substantially unable to perform his employment related duties due to his accident-related injuries. He is therefore eligible for an IRB.
28The applicant provided the respondent with an appropriate disability certificate and bank statements to prove income and employment.
29Accordingly, the applicant is entitled to receive the IRB claimed for the period of June 17, 2024 ongoing.
30I was not presented with any evidence regarding post-104 IRB entitlement and therefore will make no judgment on this.
Award
31The applicant sought an award under s. 10 of Reg. 664. Under s. 10, the Tribunal may grant an award of up to 50 per cent of the total benefits payable if it finds that an insurer unreasonably withheld or delayed the payment of benefits.
32Section 10 of Reg. 664 sets out that to be eligible for an award the respondent must have unreasonably withheld or delayed payments. In addition, the landmark Financial Services Commission of Ontario case Plowright v. Wellington Insurance Company case (FSCO A-003985, October 29, 1993) held that “Unreasonable behaviour by an insurer in withholding or delaying payments can be seen as behaviour which was excessive, imprudent, stubborn, inflexible, unyielding or immoderate.” This is the standard that I adopt for the purposes of the adjudication and evaluation of this case.
33The applicant argued that there was little or no adjustment of his file in the first six months of his claim. The applicant submitted that the respondent relied on an assessment that did not have sufficient or necessary information about the applicant’s June accident. Then, the respondent had sufficient information to adjust and provide the applicant with an IRB but did not act.
34The respondent submitted that there was no evidence of withholding or denying payments that was excessive, imprudent, stubborn or inflexible. The respondent further submitted that the issue that matters in this hearing was the amount of benefits payable after the stoppage of the IRB on June 17, 2025. The respondent argued that based on medical evidence these benefits were not payable.
35Nevertheless, the respondent’s adjuster testified that the transition to a new claim handling system may have affected the payment of the applicant’s benefits. In my view, the fact that the insurer was dealing with more than one accident on the part of the applicant, as stated by the adjuster, is not an excuse for the claim not to be handled in an expeditious manner. There are other examples of careless handling of this claim that led to payments being withheld or delayed: for example, in an explanation of benefits sent to the applicant dated December 9, 2024, the respondent says that the applicant was not attending treatment, which was not true, as we know from testimony and CNRs (the applicant was attending We Care Rehab regularly). It was also discussed in the testimony of the adjuster, Ms. Pamela Duca, that the applicant applied for benefits in both June and October with a significant delay in response according to the log notes. Despite receiving an OCF-1 in September of 2024 and a second application in that month, none are recorded in the log notes nor is the receipt of the September 12, 2024 disability certificate. The respondent’s adjuster testified that the lack of response was not supposed to happen. In addition, the respondent’s adjuster also referred to a new system at the insurer that might have confused the two claims.
36My conclusion is that there appear to be significant mistakes and a lack of attention to the applicant’s claim. I have noted instances of mistakes, gaps in the respondent’s adjustment of this file, time delays and a lack of responses by the respondent to requests from the applicant, as noted above, that show on a balance of probabilities that the respondent was indeed excessively slow or delayed in the handling of the applicant’s claim. For example, it is not clear from the respondent’s adjuster’s testimony or the log notes whether or not correct information was sent to the applicant, whether or not the applicant’s retention of counsel was noted and why correspondence from or on behalf of the applicant was not acknowledged. Despite receiving a notice from the respondent on Oct 11, 2024 that two OCF-1 documents were received, log notes indicate that only one was received. Nor was the receipt of the September 12, 2024 disability certificate from the applicant’s physician acknowledged. An OCF-3 was only acknowledged and actioned on December 9, 2024, which is an unreasonable delay.
37A new claims handling system and two separate claims made by the applicant are not an excuse for failing to handle the applicant’s claim in an expeditious and professional manner as the insurer is obligated to do, especially given the Schedule’s emphasis on consumer protection. Furthermore, in the absence of an income replacement benefit, the applicant testified that he was forced to apply for social assistance and ask his parents for financial assistance to meet his child support obligations.
38The respondent has also claimed that the applicant was not in treatment for his injuries nor provided sufficient employment and income information, and used this reason to deny him income replacement benefits. However, according to the evidence presented, the applicant was in treatment (he was sent to Lifemark for physiotherapy as recommended by the respondent), the respondent did indeed receive a confirmation of income from the applicant’s employer in addition to bank statements and a disability certificate.
39It is unreasonable that requests for information sent to the respondent went unanswered. There were also anomalies in the log notes. For example, about whether the applicant was actually sent an OCF-3 or that the applicant had retained counsel. By September, 2024, the applicant was not working and had submitted a disability certificate and doctor’s letters yet still was not able to secure income replacement benefits.
40This type of conduct by a respondent must be deterred. The respondent has an ongoing obligation to adjust files efficiently and in good faith.
41I therefore award the applicant 30 per cent of the IRB in question. The amount of 50 per cent is the maximum award, which should be awarded in the most egregious of cases. I do not find the circumstances here to be the most egregious but the respondent’s actions do fall significantly short of the standard based on the consumer protection nature of the Schedule. In my view an award 30 per cent is appropriate given the unexplained errors and delays in adjusting the applicant’s claim, including the evidence that showed repeated requests from the applicant and his representatives for an answer, and the receipt of required documents only to still have the claim for IRB denied.
42The IRB owing in this case is from June 17, 2025 to the date of the hearing, October 28, 2025, which is 19 weeks. At a quantum of $400/week, the IRB owing is $7,600.00 multiplied by 30% = $2,280.00.
Interest
43Interest applies on the payment of any overdue benefits pursuant to s. 51 of the Schedule.
Costs
44The applicant is not entitled to costs.
45The applicant requested costs be paid. The applicant submits that the respondent did not attempt to rectify any errors they made in adjusting the applicant’s claim and instead decided to go to a hearing.
46Rule 19.2 provides that a request may for costs may be made at any time before the decision or order is released. Rule 19.5 sets out the grounds for a finding of costs on any party.
47According to Rule 19.5, in deciding whether to order costs and the amount of costs, the Tribunal considers all relevant factors including the seriousness of the conduct, whether the conduct was in breach of a direction or order issued by the Tribunal, whether or not a party’s behaviour interfered with the Tribunal’s ability to carry out a fair, efficiency and effective process, prejudice to other parties, and the potential impact on individuals accessing the Tribunal system.
48The Tribunal must consider totality of parties’ conduct and whether it actually interfered with the Tribunal’s ability to carry out a fair, efficient and effective process; prejudice to the other parties, and access to other individuals accessing the Tribunal. In my view, the respondent’s actions did not prevent a fair, efficient and effective hearing. There has been no threat to the orderly and civil resolution of the applicant’s application or claim. To allow a claim for costs means that there must be a course of conduct that frustrates the Tribunal’s ability to carry out a fair and efficient hearing. I do not find that to be the case here.
49Costs are not intended to compensate parties for the cost of bringing or defending claims or to punish a party. If the applicant chooses not to provide submissions or evidence when they have the onus to prove their case, then their claim will fail.
50In this case, the hearing was conducted. I am not persuaded that the respondent’s failure to adjust the claim expeditiously alone is grounds for an award of costs. The applicant did not present any other reasons for their cost claim.
51For these reasons, the applicant is not entitled to costs.
ORDER
52Based on the evidence provided and the testimony of the witnesses, I find that on the balance of probabilities:
i. The applicant is entitled to an income replacement benefit in the amount of $400.00 per week from June 17, 2025 ongoing.
ii. The applicant is entitled to an award of $2,280.00.
iii. The applicant is entitled to interest.
iv. The applicant not entitled to costs.
Released: February 6, 2026
__________________________
Neil Levine
Vice-Chair