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Why doesn’t the insurance company believe that I’m injured? (Ontario)

If insurers paid out maximum compensation on each and every claim, there wouldn’t be any need for personal injury lawyers or paralegals who focus on benefit accident claims.

Why does an injured accident victim or disability claimant need a lawyer, if the insurer is paying them out the full value of their claim up front; without any hassle?

But, if an insurer paid out the maximum value of each and every claim which came across their table, chances are they wouldn’t be as profitable as they are; or profitable at all.

As much as we are made to believe that insurers are there to look out for our best interests and pay out when they are supposed to; at the end of the day; insurance companies exist to MAKE MONEY.

Many Canadian insurance companies trade on the Toronto Stock Exchange (TSX). Here are a few examples along with their stock symbols, along with current share values as of the time of preparing this Toronto Injury Lawyer Blog Post on July 7, 2015:

Intact Financial Corp: IFC $90.57

Sun Life Financial: SLF $41.80

Manulife Financial: MLF $23.03

Co-Operators General Insurance: CCS-PS $23.79

Those are just a few of the examples of insurance companies which do business in Canada, who trade of the Toronto Stock Exchange.

Those stock symbols and share prices are VERY important. If those share prices drop significantly, millions, if not billions of dollars will be lost value and options for shareholders around the world.

If one of these insurers paid out ALL claims, regardless of merit of an entire year, chances are those stock values would dip dramatically.

So, when accident victims or disability claimants wonder why so many claims are denied at first instance, or why insurers refused to believe what their doctors have to say about their injuries, there is a financial reason for this.

The more money an insurer pays out to your for your claim, the less money they get to report in profits for their share holders.There are certainly a variety of their factors involved in insurer profits, but this is one of the most tangible concepts for accident victims and disability claimants to understand.

So, when a client wants to know why the insurance company won’t believe the severity of their injuries or the nature of their disability, this may be because they simply don’t want to, because it affects their bottom line.

Also think about their co-workers and their denial or approval rates. If one adjuster approved 90% of claims which crossed their desk, but the average approval rate was 40%; it would certainly raise some concerns for management. Is this adjuster just getting a majority of meritorious claims? What is this adjuster doing differently, in comparison with all of the other adjusters they are working with? There are targets which some adjusters need to meet with respect to their claims. If these targets are not met, or conversely are way out of proportion with the averages; then that adjuster will have a problem. Another reason why claims can get denied so frequently at first instance.

Our lawyers have also seen cases of simply negligent or incompetent insurance adjusters. Refusing to read over medical records, refusing to follow proper claims handling and adjusting protocols and procedures; not sending out letters or notices when they are required at law to do so; or simply not believing the overwhelming medical evidence presented in a case.

One of the most common reasons we see that insurer deny claims, or refuse to believe a claimant’s disability may come down to “independent medical reviews” or “independent medical examinations”.

These assessments can be done in person. Sometimes, they are conducted by way of paper review. In the case of a paper review, the insurance company will send all of the medical information and other documentation they have in relation to a particular claim; over to a doctor, or rehabilitation professional in order to assess the merits of the claim. Keep in mind, that this type of assessment is done WITHOUT meeting with, or even speaking to the injured Plaintiff.

This may seem strange to you; and it has always seemed strange to me and to the lawyers at my office. For something so important as somebody’s claim and entitlement to compensation/benefits; it all rests with a doctor essentially reviewing the paper work that’s made available to them at that particular time. No meeting. No interview. No physical or psychological assessment.pan am

Regardless of how strange or unfair you believe this practice to be, it remains common practice in the industry. I have never been given an explanation as to why that is; aside from conducting a paper review is cheaper and faster than conducting a full in person assessment. When so much is at stake, it continues to feel so wrong.

But, our our law firm, we aren’t all pessimistic that your claim will be denied at first instances. Sometimes a form isn’t filled out properly, or more medical evidence is required. In those cases, writing a few letters and making sure all of the I’s are dotted and T’s are crossed is all it takes. We are cautiously optimistic that your claim will get approved and that you won’t need a personal injury lawyer. Other times, the reason for the denial is a simple miscommunication between the insurance company and the claimant. Helping buffer that communication between claimant and insurer is just one of the things we do on behalf of our clients.

Enough law talk? Sure. I would like to comment on the Pan Am Games which are coming to Toronto at the end of the week. This will be Toronto’s first major international/continental sporting event in a very long time. With all due respect to the Pan Am games; I have never really heard of you until NOW. I’m glad you’re bringing together athletes from across North American, South America and the Caribbean to compete, but are you really a big time sporting event deserving of disrupting a big time city like Toronto? These games have been hosted by Winnipeg twice. With all due respect to Winnipeg; it’s no Toronto. I know. I’ve explored Winnipeg at great length. Is Toronto going to care, or appreciate the games? My guess is YES: Torontonians will unite and appreciate the spirit of the games. But, I don’t think the Pan Am Games are a big enough or prestigious enough event to completely disrupt the flow of this “world class” city for 2-4 weeks in July. It feels like Toronto couldn’t get the Olympics, or the Men’s World Cup, or the Women’s World Cup; so we will have to settle on hosting the Pan Am Games; which I see as a second tier event. Yes: I just called out the Pan Am Games. I’m certain that millions of other Torontonians would agree. Legacy of the Pan Am Games? The long overdue Union Pearson Express, along with some first class aquatic facilities, a velodrome and a fieldhouse. It shouldn’t take the Pan Am Games to get these facilities in place.


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