Your Records vs. The Insurance Company’s Experts

When your patients are in disputes over accident benefits, the License Appeal Tribunal (LAT) has to decide whose opinion to trust: your clinical notes and treatment recommendations, or the insurance company’s independent examiner.

Your clinical notes can be the evidence that wins your patient’s case, or the gap that loses it.

What the LAT is Actually Looking For

The LAT isn’t just reading your notes, they’re asking:

• Do these records show that this patient needs treatment?
• Do they show that the patient is disabled?

Here’s what tips the scales in your patient’s favour:

1. A Clear Paper Trail of Ongoing Symptoms

The LAT wants to see that symptoms didn’t just exist, they were consistently documented over time.

What wins cases:

• Recording pain complaints, psychological symptoms, or functional limitations at every visit
• Not just “patient reports pain” but specifics: location, severity, impact on daily activities

Real examples:

• Oliveira v Aviva, 2025 – Doctor repeatedly documented psychological complaints. LAT chose these notes over the insurance examiner who said no psychological issues existed.
• Barabash v Pembridge, 2023 – Consistent pain notation at each visit and comments regarding the benefits provided by therapy beat the IE’s conclusion that patient had reached maximum recovery and treatment was not required.

What loses cases:

• A.Y. v Aviva, 2019 – No mention of psychological symptoms for 5.5 months = LAT concluded no psychological issues from the accident
• P.N.S.T. v BelairDirect, 2020 – No evidence of ongoing treatment in records = LAT concluded patient wasn’t impaired

2. Active Treatment Plans, Not Just Observations

The LAT looks for evidence you’re not just documenting, you’re actively managing the patient’s care.

What wins cases:

• Making referrals to specialists
• Recommending specific treatments
• Prescribing medications or therapies
• Changing the treatment not continuing the same treatment for a long time if it’s not working

Real examples:

• Campbell v TD General Insurance, 2022 – Your referral for treatment proved it was medically necessary.
• Zeb v Economical, 2022 – Multiple treatment referrals supported the claim that were rejected by the IE

What loses cases:

• J.P. v Aviva, 2020 – No referrals or treatment recommendations = LAT determined no need for attendant care benefits

3. Your Advantage: You Actually Know the Patient

You’ve seen this patient over months or years. The insurance examiner spent 40 minutes with them.

Real examples:

• N.P. v Wawanesa Mutual, 2020 – Family doctor’s understanding of the patient’s unique medical condition beat a brief IE
• J.C. v Aviva, 2020 – Ongoing treatment records beat a 40-minute insurance exam

But this only works if your records reflect that depth of knowledge. If your notes are sparse or generic, you lose this advantage.

The Tricky Issues That Hurt Claims

Pre-Existing Conditions: They’ll Find Them Anyway

Don’t avoid documenting pre-existing issues, they’ll come up in the insurance examiner’s report anyway. But when they’re in your records without context, they can be used against your patient.

What happened:

• Ma v Co-operators, 2023 – Pre-accident issues in family doctor’s records led to a supportive psychiatric report being discounted because the psychiatrist noted the patient denied pre-existing issues
• Crecoukias v TTC, 2022 – ODSP application in doctor’s records noting only moderate impairment contradicted catastrophic impairment claim

Better approach: Document pre-existing conditions and document how the accident made them worse or different.

Inconsistencies Without Explanation

When your records contradict other evidence or seem inconsistent, it undermines your credibility, unless there’s a clear explanation.

What happened:

• Binet v Liberty Mutual, 2021 – IE orthopedic surgeon’s opinion preferred because family doctor’s records had unexplained inconsistencies

The Bottom Line: What to Do

Your notes should tell a story:

1. What the patient is experiencing (symptoms, limitations)
2. How it’s impacting their daily life
3. What you’re doing about it (referrals, treatments, medications)
4. How they’re responding (improving, stable, worsening)

Be specific:

• Not just “pain” but “7/10 pain in lower back, limiting ability to sit for more than 30 minutes”
• Not just “anxious” but “reports panic attacks 3x/week, difficulty leaving home”

Be consistent:

• Document at every visit, not just when it seems important
• If symptoms improve, document that too (it shows you’re tracking progress)

Be proactive:

• Make referrals when indicated
• Explain what will happen to the patient if recommendations are not implemented
• Treatment can be necessary to prevent clinical decline and maintain function.
• Recommend treatments
• Show you’re actively managing their care

Questions About Your Patient’s Accident Benefits Claim?

Your clinical records play a crucial role in your patient’s ability to access the treatment and benefits they need. If you have questions about how to support your patient through the accident benefits process, we’re here to help.

This guide is based on publicly available LAT decisions and is provided for informational purposes only. It does not constitute legal advice.