Many people who are receiving accident benefits will be surprised and disappointed when their benefits begin to be denied. Many people believe that a single denial means they have been “cut-off” entirely from receiving any further benefits. In fact, this is not the case. Insurers are required to assess each individual treatment plan or application for benefits to determine whether they are reasonable and necessary. Often, an insurer will request a medical examination to help make this determination. Many people are disappointed with the outcomes of their insurer medical examinations or feel the results of the examinations do not accurately reflect the severity and impact of their injuries.
If a person has been denied a particular benefit, they must apply to the Financial Services Commission of Ontario (“FSCO”) to mediate the denied benefit. FSCO is required to schedule a mediation of the dispute within 60 days of receiving the application for mediation. However, many injured people find that the wait time for a mediation date is much longer.
At a FSCO mediation, the insurer and the injured person (or his or her lawyer) will attempt to negotiate a resolution of the disputed benefit. If more than one year has passed since the date of the accident, the insurer may attempt to pay a lump sum amount to close the accident benefits file on a full and final basis. When considering whether to accept a lump sum pay out of an accident benefits file, an individual should consider, among other things, what his or her long term needs might be and what potential entitlement to accident benefits he or she may have under the accident benefits legislation.
If mediation does not successfully resolve the dispute with one’s insurer, then an individual may choose to either file a Statement of Claim with the Superior Court or apply for an arbitration through the FSCO. Ultimately a judge or arbitrator will be called upon to determine whether or not the disputed benefit should be provided. There are specific deadlines for filing a Statement of Claim or applying for arbitration. If these deadlines are not met, the injured person may be precluded from recovering the benefits he or she is seeking, even if the claim for benefits had merit.
This posting is meant to provide basic and general information, not legal advice. Individuals should hire a lawyer to obtain legal advice on the particular facts and circumstances related to their case.