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Why aren’t my accident benefits getting paid? (Ontario Case Study)

We get lots of calls at our law firm from accident victims across Ontario all with the same simple inquiry:

I’ve been hurt in a car accident. I applied for accident benefits through my car insurance company. And now the car insurance company isn’t paying any accident benefits! Why is that and what can you do to help me?

Our lawyers do our very best to help every person who calls our office with such an inquiry. We understand that people become very dependent on the benefits which an insurance company provides for them following a serious car crash. An insurer may pay you up to $400/week for an Income Replacement Benefit. They may pay you up to $1,500/month in an Attendant Care Benefit. They may also be paying for your massage, physiotherapy, pain management clinic, psychological counseling, or some other form of treatment which is not covered by OHIP. On the other hand, an insurance company may refuse to pay you anything.

There are plenty of reasons why your accident benefits might not be getting paid. Maybe you’ve changed your address and you haven’t replied to any letters which the insurance adjuster has been sending you? Maybe the insurance company hired a private investigator to take photos/video of you and caught you doing the death walk along the top of Toronto’s CN Tower. Maybe you haven’t even completed the requisite paperwork to get your case started in the first place.

Whatever the reason for your claim getting denied, don’t take the fact that your car insurance company isn’t paying your accident benefits personally. It’s no reflection on you as a person. It’s simply a part of the business of car crashes and insurance law in Ontario.

The fact is, that if insurance companies automatically paid out everyone’s accident benefits, they would report less profits for their shareholders. Sad, but true. So, if they can find a loophole NOT to pay out your benefits, why wouldn’t they take advantage of it?

Another very sad tidbit which you ought to know is that insurance companies would rather spend lots of money on so called “independent medical assessments”, rather than pay benefits to you. Actuaries have weighed in on the cost of of paying out so called “Independent Medical Experts” vs. paying out on claims. Actuaries have found that paying out medical experts more money to DEFEAT your claim, than actually paying out money in benefits to get you better following a car accident is more profitable.

Whether you had a serious motor vehicle collision, or a minor fender bender, the strategy will generally be the same. The more money which an insurer can preserve, the more profits which they can report.

Here in Ontario, an insurer gets to play the role of Judge, Jury and Executioner. They hold all of the cards with respect to denying, or approving your claim. The test, is whether or not the benefits claimed are “reasonable & necessary“. What’s reasonable & necessary in your eyes, will certainly be different that what’s reasonable & necessary in the eyes of an insurance adjuster. Now, don’t get me wrong, there are some very level headed insurance adjusters out there who do a great job both for their employers and for their clients (the accident victims). But there are also bad insurance adjusters out there, and once they sink their teeth in to your claim, you will be in for the fight of your life.

Even more troubling in Ontario is the wide array of forms which the client must complete, sign, submit within certain time frames in order to qualify for benefits. If you fail to complete these forms in a timely manner, or fail to complete them properly, or believe that you’ve completed the forms properly (but they weren’t), you will be found in non-compliance under the SABS and your claim will be denied. These procedural hurdles for an car accident claim are troubling to any client. It’s like you need a rocket scientist (or just a really good personal injury lawyer) to complete these forms (which you do!).blue-seal-187-130-altman-altman-llp-113593.png

What saddens me even more is when I see peoples’ benefit claims getting denied, when the person themselves don’t even know that they’ve been denied. Even more painful is when they call our office, not knowing they’ve been denied, and after we review the file we determine that they’ve been denied for so long that they’ve missed out on a limitation period and their claim is now statute barred. There’s nothing more disappointing for a client and no harder news for a lawyer to deliver.

There are different tests for disability in order to recover income replacement benefits, non-earner benefits and attendant care benefits. In addition to these tests for disability, the claimant must also meet certain economic criteria. In the example of the non-earner benefit, the client must not have been working or not earning an income in the year or so before the car crash. In the case of an income replacement benefit, this will only cover 80% of a client’s net pre-accident income. In some instances, where there is Canada Pension Plan Disability Insurance, EI, or Long Term Disability Insurance, the car insurer will be entitled to a set off which results in a nil payout on their behalf. In the case of the Attendant Care Benefit, the accident victim will need to show firstly that they are disabled by preparing a FORM-1; and in addition, the expense needs to be incurred from the client to the care provider. Translation, the insurance company actually requires proof of payment from the injured party to the care provider! Talk about red tape!

Nobody said that car insurance in Ontario was easy. On the contrary, as the years go by, the more and more complex the SABS become. The SABS have become so complex in fact, that Insurance Laws are changed around once every 3-4 years, and the Financial Services Commission of Ontario has been created specifically to deal with accident benefit disputes in Ontario.

Ever want a chance to see a Arbitration at FSCO? You can attend an Arbitration in person at the offices of the Financial Services Commission located at 5160 Yonge Street, in Toronto, right down the street from the offices of Goldfinger Law. But let me tell you, the hearings at FSCO are like nothing which you see on the movies or in television. Far less exciting and far less drama.

Keep in mind that every car collision is unique, just like every person is unique. Hence, every case is unique. If you have any unique questions about your legal case, give us a call. We’d be happy to help you out any way that we can.

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