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Insurer Medical Examinations in the context of your Injury or Disability Case: But Do I really have to attend? (Ontario)

You’ve been injured in a car accident, or you’ve made a claim for Long Term Disability Benefits.

Benefits have not yet been paid. The insurance is giving you a tough time. They’re treating you like you’ve done something wrong; when all you’ve done is been in the wrong place at the wrong time resulting in serious injuries. All you want are the benefits you need to help you get better, and make ends meet. After all, isn’t that what insurance is for? Isn’t that why you’ve paid mountains of money in premiums all of these years.

You receive a notice in the mail from your insurer. They want you to attend an IME (Independent Medical Examination) with some doctor or therapist who you’ve never heard of, in a strip plaza or office tower that’s far away from home.

Transportation has been arranged, but the assessment is still going to take up a lot of your time.

You have yet to receive any benefits so why should you bother to attend? You don’t want some strange doctor or therapist touching you, or asking you all sorts of personal questions, and then reporting their findings to strangers at the insurance company. It all seems weird. And who’s paying for these examinations anyway? They aren’t covered by OHIP, and you know that doctors’ time isn’t cheap.

If the request for an IME is as a result of a car accident, unfortunately, the Insurance Act and the Statutory Accident Benefits Schedule (that’s the law dealing with car accident benefit claims) requires that you attend.

Here is an excerpt of the relevant section of the SABS:

Examination Required by Insurer

42.  (1)  For the purposes of assisting an insurer determine if an insured person is or continues to be entitled to a benefit under this Regulation for which an application is made, an insurer may, as often as is reasonably necessary, require an insured person to be examined under this section by one or more persons chosen by the insurer who are members of a health profession or are social workers or who have knowledge in vocational rehabilitation. O. Reg. 546/05, s. 21.

So, you’ve now read the law which basically requires your attendance at these examinations. Still..what happens if you just don’t go? Read on and we will tell you!

The law is cruel. The way that the car insurance, and long term disability insurance legal system is cruel as well.

In most cases, the Plaintiff is an injured accident victim who can no longer work, function, or lead a normal life on account of a serious accident or trauma.

The Plaintiff is a person. They are often without money to make ends meet following an accident. They are struggling to make rent payments, mortgage payments, or purchase food and clothing for the families.

Treatment to get better is more often that not; NOT covered by OHIP. There are very few OHIP Funded Physio clinics in Ontario. Those which do exist have long wait lists, and the treatment is not as thorough as you would receive through other private clinics. This does not take in to consideration any psychological injury needing therapy or counselling, or any Occupational Therapy or social work services…all of which are NOT covered by OHIP outside of the hospital setting.

So, we’ve established that he Plaintiff is in NEED of something. Whether that something is money, treatment or both, they NEED something.

The insurer on the other hand needs NOTHING from you. They don’t need money for your claim..they’ve already collected your premiums for that long ago. They would sooner you DIE rather than have to deal with handling your claim. If you die, then there are no longer on going benefits which they have to manage. If you die on account of a car accident, they can simply pay the funeral death benefit, perhaps throw some money for grief counselling for a loved one; and poof…the claim magically goes away.

Contrast that fatality claim to that of a catastrophically injured accident victim who is paraplegic and brain injured following a serious car accident. That claim would involve monthly, if not weekly benefit payments for an income replacement benefit or a non earner benefit along with all of the associated attendant care or treatment costs. This would not only be a lot of work for the insurance adjuster; but it would also be a very expensive claim for the insurer to handle.

Because the Plaintiff has a need for benefits; and the insurer could care less about paying out those benefits, unfortunately, the Plaintiff has got to jump through some hoops to get those benefits.Gio

We tell people if you’re seeking their benefits; you have to play by the rules..and unfortunately, those rules are skewed against Plaintiffs like you. But if you don’t want any benefits; then by all means..don’t attend at the IME. The result for failing to attend at an IME is non compliance under the SABS, and your benefits are either withheld or suspended.

Lesson: Sometimes, you have to play by their rules, and their rules often require attendance at these examinations.

Most of what I’ve written thus far has been in the context of car accidents. But, the same concept applies to Long Term Disability Claims. In EVERY LTD policy I’ve ever seen, there is a section regarding attendance at medical assessments or examinations at the request of the LTD insurer. Failure to attend at these examinations will result in a denial or termination of benefits on account of non-compliance or a violation of the policy.

There are certainly limits on the amount or number of examinations which an insurer requires that you attend. That number is entirely dependant on the value of your claim, the nature of your injuries, the complexity of those injuries, what examinations have previously taken place, what the medical records show and what benefits are being sought by the Plaintiff. There is no hard and fast rule in the context of accident benefit claims, or NON LITIGATED LTD claims on the number of examinations an insurer can request that you attend. You should consult with a personal injury lawyer before you attend at one of these examinations to determine if you’re doing the right thing or not.

Here’s a thought: You attend at one of these examinations and the report comes out favourable to your claim. The IME doctor agrees that you need weekly income benefits AND treatment. WOW! How’s that for optimism. You never know. More often than not, these reports come back denied and in favour of the insurer. But, there is the odd occasion when these reports come back in favour of the Plaintiff. You never know.

Enough law talk? Sure. I was at the TFC game on Saturday night with a friend of mine. Soccer is known as a flowing game. This was hardly a soccer match. 8 Yellow Cards with countless stoppages on account of fouls or simply dirty unfair plays. The entire experience tarnished me from ever returning to BMO Field for another TFC game. One team was out to play soccer. The other team was out to cause harm and disrupt the beautiful game. It was exactly the thuggery which others in Europe think about when MLS comes to mind..A bunch of unskilled thugs featuring an ageing, skilled designated player from Europe at the end of his career.

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