In this article, we will be reviewing the case decision of Gromova v. Primmum Insurance Company, 2026 CanLii 18336 (ON LAT) [1] March 5, 2026.
On November 8, 2022, Ms. Irina Gromova was involved in an automobile accident. She sought benefits pursuant to the Statutory Accident Benefits Schedule (SABS).
Ms. Gromova, the applicant, was denied benefits by the respondent, Primmum Insurance Company. She applied to the License Appeal Tribunal to resolve the dispute.
The respondent argued that the applicant did not attend multiple IEs related to a physiatry examination in order to determine the necessity of a chronic pain assessment.
The issues noted to be in dispute were two-fold.
Ms. Gromova applied for physiotherapy, chronic pain and neurological assessment. This application was denied and sent to a physiatrist IE.
The respondent denied the chronic pain assessment submitted on the OCF-18 dated June 16, 2023. While the respondent denied the claim in a reasonable time frame, on June 20th, 2023, they failed to schedule the related physiatry IE in a timely manner.
A notice letter for the physiatry IE to determine entitlement to this claim was sent to the applicant on September 5, 2024, which is 13 months after the claim had been submitted.
Moreover, the respondent had scheduled two other IEs for June 22, 2023, and June 23, 2023, related to psychology and neurology IEs, but provided no explanation as to why the physiatry IE was not scheduled.
Under section 44, an insurer may require an insured person be assessed for entitlement of benefits under the SABS by examining them at an IE [2].
However, the examination must not be more than what is “reasonably necessary.”
The preliminary issue at hand was whether the applicant was barred from proceeding to a hearing for a chronic pain assessment due to the applicant failing to attend an insurer’s examination (“IE”) under s. 44 of the SABS.
According to section 55(1)2 of the SABS, “an insured person shall not apply to the Tribunal if the insurer has provided notice that it requires an examination under section 44, but the insured person has not complied with that section” [2].
Based on this information, the Tribunal found the applicant to not be barred from proceeding to a hearing on the issue of a chronic pain assessment due to not attending an IE, as the physiatry IE was not scheduled for over a year after the denied claim, making the timing of the IE unreasonable.
Additionally, the Tribunal found the applicant entitled to physiotherapy services, a chronic pain assessment, a neurological assessment, and interest on overdue benefits.
This was related to a lack of explanation as to why the chronic pain assessment was denied and relying on generic “Minor Injury Guideline” language without clear medical reason for denying the physiotherapy treatment plan when the applicant had “concussion” listed under their primary injury and sequelae on the submitted OCF-18.
Similarly, the neurological assessment was approved as the applicant had provided medical documentation from her family physician indicating the following symptoms: “headaches on/off and nausea, light headedness/dizziness and neck pain” [1].
Moreover, while neurological assessments may be covered by OHIP, the insurer failed to provide that the assessment was reasonably available through OHIP for the applicant, hence the Tribunal noted that coverage was not excluded for this.
As benefits were overdue, the applicant was also found to be entitled to interest under section 51 of the SABS.
The main lesson from this case is that it is the onus of the insurer to provide explanation for denials and to arrange IE assessment in a reasonable timing post denial of services.
At GLA Rehab, our referral coordinator is communicating with insurers on a daily basis to understand the reason for denials and to use compelling arguments on the necessity of any service identified by our clinicians as helpful.
You can contact us at www.gla-rehab.com.
References
[1] Gromova v. Primmum Insurance Company, 2026 CanLII 18335 (ON LAT), https://canlii.ca/t/kjn4w
[2] O. Reg. 34/10: Statutory Accident Benefits Schedule – Effective September 1, 2010, https://www.ontario.ca/laws/regulation/100034