Insurer Examinations and Disability Benefits

A recent legal decision involving a bodily injury claim puts an added onus on insurers and adjusters when it comes to requiring Insurer Examinations.

Speakers at a recent symposium for the legal profession hosted by MDAC (Multi Disciplinary Assessment Centre), gave a talk where they pointed out that an insurer was assessed with penalties by reason of having demanded Insurer Examinations without providing reasons to substantiate the request (Financial Services Commission of Ontario decision – Augustin v. Unifund; FSCO A12-000452, November 13, 2013).

Previous decisions have favoured insurers in deciding that they did not have to pay accident benefits if the accident victim didn’t show up for a scheduled Insurer Examination (IE) without good reason. However, this new ruling of the Financial Services Commission of Ontario puts the onus back on the insurer to prove reasonable grounds for requiring the IE in the first place.

The Case

The woman in question was injured in a car accident in 2011 and claimed medical and attendant care benefits along with a weekly benefit for her continued inability to work or lead a normal life (adjusted for the fact she had been unemployed at the time of the accident). What happened then is unfortunately typical.

  • Her insurer refused to pay after she failed to attend Insurer Examinations they’d called for to determine the extent of her injuries.
  • They also denied her right to mediation and to the income replacement benefit, claiming she had not applied for it.

Section 38(9) of Ontario Regulation 34/10, also known as the Statutory Accident Benefits Schedule, sets out definitions and limitations as to how different injuries are to be assessed but it also sets out the responsibilities of the insurer, namely, to provide “the medical reasons and all of the other reasons why the insurer considers any goods or services, or the proposed costs of them, not to be reasonable and necessary.”

You Need Expert Help

It’s only right that insurers should be very careful in providing reasonable grounds for why Insurer Examinations are required in the first place. The laws governing automobile insurance claims have changed and clearly some issues are subject to interpretation. One thing you can count on is that insurers will be looking for the interpretation that limits what they pay out in claims.

Call the expert Disability Insurance Lawyers at Petrillo by calling (905) 949-9433 and let us help protect your rights.

We Focus On Personal Injury & Motor Vehicle Accident Claims

Petrillo Law has been providing competent, caring legal advice to disability insurance clients in Mississauga, the Greater Toronto Area (GTA) and across Ontario for over 20 years. We can evaluate a case to determine whether it meets the provincial threshold required to start a lawsuit as well as represent injured people who have been denied accident benefits by their own insurance company.

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