What happens if my insurer denies my claim for Accident Benefits?

The SABS allows for insurance adjusters to deny benefits for medical and rehabilitation costs for “medical and any other reasons” without obtaining a medical examination. Moreover, they can also deny applications for a catastrophic injury designation for the same reasons, also without obtaining a medical examination.

The Insurance Act of Ontario prohibits insurers from engaging in unfair or deceptive practices. You have remedies available to you if your insurer has wrongfully denied your claim or has:

1. Failed or refused to pay a claim for goods or services or for the cost of an assessment within the time prescribed for payment in the SABS without reasonable cause; and
2. Made a statement by or on behalf of the insurance company for the purposes of an adjustment or settlement of a claim while knowing that the statement misrepresents or unfairly presents the findings or conclusions of a person who conducted an examination under section 44 of the SABS.

If your insurer refuses to pay you the amount claimed, you are entitled to appeal this decision before the License Appeal Tribunal (“LAT”). The application must be brought within two years of the insurer’s refusal and in accordance with the Insurance Act of Ontario. Generally, the process goes as follows. First, a case conference is held where an adjudicator tries to resolve the issues by mediation. If this fails, the parties proceed to a hearing.

Once mediation prescribed by the statutory scheme has failed and/or the expiration of the prescribed time period for mediation passes, you can pursue the commencement of court actions.

A personal injury lawyer can step in to help you with claims brought before the LAT.