Your Insurance Company will assign an adjuster to manage your claim.
The adjuster will arrange for a medical assessment to determine the classification of your injuries.
Your injury will fall into one of three categories and the money available for treatment and expenses varies for each category. Remember if you did not purchase indexing, these amounts are fixed.
- Minor Injury Guideline – Limit of $3,500.00 with income support and medical expenses for a maximum of six (6) months
- Almost Catastrophic or Non-Minor – $65,000.00 with Medical and rehabilitation benefits, attendant care, income replacement benefit, and other benefits depending on coverage purchased with your policy.
- Catastrophic – The compensation is subject to many variables.
The insurance adjuster handling your file will do their best to keep you in the Minor Injury Guideline unless your injuries are obvious.
If you decide to have a medical practitioner do an assessment for you, it will have to be submitted on an OCF form relative to your claim. The insurance company will not reimburse you for any expense not pre-approved by them. This typically triggers the adjuster to schedule an assessment of their own to counter your submission and either deny or greatly reduce your request to minimize their costs. Forms link can be found under the resources section and are under review for updating by FRSA (Financial Services Regulatory Authority of Ontario)
With the case I am following, the initial doctor dismissed the injuries as bruises, sprains and suggested the loss of memory would come back. The words ‘You will be fine, all you have are minor bruising and sprains’ after discussing their love of automobiles for 75% of the assessment and doing a quick review of the patient leaving the process very suspect.
Unfortunately, a broken wrist as well as other injuries, despite the pain and discomfort being brought to the attention of multiple doctors were missed. This patient after several years has been independently diagnosed by one of the doctors that wrote the Provincial guidelines for catastrophic injuries, as catastrophic.
The insurance adjuster used his authority to have an assessment done by a practitioner of their choice and determined this patient is not catastrophic.
This patient’s only course of action to dispute was outlined at the bottom of the insurance adjuster’s response:
YOUR RIGHT TO DISPUTE THE INSURANCE COMPANY’S DETERMINATION OF YOUR CLAIM FOR
STATUTORY ACCIDENT BENEFITS
Under the Insurance Act, if your claim for statutory accident benefits has been reduced or denied by your insurance company, you have a right to dispute your insurance company’s determination.
If you do not agree with the insurance company’s decision you may file an application with the Licence Appeal Tribunal (LAT) – Automobile Accident Benefits Service (AABS) within 2 years of the date of reduction or denial.
WARNING: TWO YEAR TIME LIMIT
You have TWO YEARS from the date of your insurance company’s refusal to pay, or reduction of a benefit, to file an application with the Licence Appeal Tribunal – Automobile Accident Benefits Service. If you do not apply within two years, you will lose the right to dispute the determination.
Your insurance company may have an internal complaint review system. While you are encouraged to work with your insurance company to settle your complaint, be warned that it does not extend the two year time limit to make your claim.
HOW TO FILE AN APPLICATION TO THE LICENCE APPEAL TRIBUNAL – AUTOMOBILE ACCIDENT BENEFITS SERVICE
To file an application you must complete the following steps:
- Complete an AABS Application by an Injured Person (the “application”);
- Send a copy of the application to the insurance company (this is called ‘serving’ the other party);
- Complete an AABS Certificate of Service to explain how you have sent the copy of the application to the other party; and
- Submit the completed application and the Certificate of Service to AABS and pay the AABS application fee.
Forms
The forms can be downloaded and can be filled in on a computer or by hand. For more information on forms and serving
documents please visit: AABS: Forms | Tribunals Ontario
If you need a paper copy or if you have questions about the forms or process, please call AABS at 416-326-1356 from
the Toronto calling area, or toll-free at 1-888-444-0240.
Fee
GS: Filing and Fees | Tribunals Ontario
How to Submit Your Application
BY MAIL:
Automobile Accident Benefits Service
Licence Appeal Tribunal
15 Grosvenor Street, Ground Floor
Toronto, ON M7A 2G6
Attention: Registrar
Hours of Operation: AABS’ hours of operation are Monday to Friday, 8:30 a.m. to 5:00 p.m.
Unfortunately, this process can take some time to complete and is an approach used by the insurance adjuster to stall you and perhaps make it not worth your while to pursue based on cost.
Your Insurance Company claims empathy to your situation when you file a claim for injuries and retains specialized third-party companies that uses adjusters to manage your case. These companies claim to treat the insurance company’s customers like their own. Their mission statement typically reads like this example of web posting:
‘The work of restoring lives means engaging with people at some of their most difficult and vulnerable moments. You need to know that your claims handling partners are treating your customers with the dignity and respect they deserve.
At XXXXXXXX, we’ve built a long-lasting business on the principle of “honesty and integrity above all.” Every member of our team is committed to ensuring that your customers receive the best possible support, care, and commitment.’
While very meaningful sounding, from personal experience I can tell you, this is not the case as they are financial portfolio managers looking to minimize the loss for their client, the Insurance Company.
Do not forget that your family doctor is the key to your recovery and should be kept up to date with all assessment reports that you have experienced.