Car accidents can be a life-altering experience. On top of physical injuries, you might be facing lost wages, medical bills, and rehabilitation costs. Fortunately, Ontario’s no-fault insurance system offers Accident Benefits (AB) coverage to help manage these expenses. However, insurance companies may deny your claim entirely or limit the benefits you receive. If this happens and you believe the decision is unfair, don’t give up! Here’s a roadmap to navigate a denied AB claim in Ontario.
Understanding the Reasons for Denial
The first step is to understand why your claim was denied. Common reasons include:
- Lack of Evidence: The insurer might feel you haven’t provided enough proof linking your injuries to the accident. Ensure you have detailed medical records, police reports, and witness statements.
- Pre-existing Conditions: The insurer may argue your injuries existed before the accident. Gather medical records demonstrating a pre-existing condition wasn’t the primary cause of your current limitations.
- Treatment Disputes: Disagreements can arise regarding the necessity or cost of a specific treatment. Seek support from your doctor with clear documentation outlining the medical basis for the treatment.
- Benefit Maximums: Your policy might have limitations on specific benefits, such as physiotherapy or income replacement. Review your policy to understand coverage details.
Requesting Reconsideration
It’s always best to try resolving the issue directly with your insurer. Contact their claims department and explain why you believe the denial was wrong. Be polite, persistent, and reference any additional evidence you’ve gathered.
Obtaining Legal Guidance
An experienced personal injury lawyer specializing in AB claims can be invaluable. They can:
- Review your policy and denial letter: A lawyer can ensure your policy covers the benefits you’re seeking and identify any legal grounds to challenge the denial.
- Gather additional evidence: They can help collect medical reports, specialist opinions, and other documentation strengthening your case.
- Navigate the appeals process: Lawyers understand the complexities of AB disputes and can guide you through the appeals process with the Automobile Accident Benefits Service (AABS), a branch of the Licence Appeal Tribunal (LAT).
The Appeals Process with AABS
If your request for reconsideration is unsuccessful, the next step is to file an Application with AABS. There are strict timelines for filing, typically two years from the date of the denial. The AABS offers resources and guidance to help you complete the application process.
The AABS will attempt to mediate a settlement between you and the insurer. If mediation fails, a formal hearing will be scheduled before a LAT adjudicator. Here, both parties present their arguments and evidence. Having a lawyer represent you at this stage is highly recommended.
What to Expect at a LAT Hearing
LAT hearings are typically less formal than court proceedings. However, they can still be complex. Your lawyer will guide you on what to expect and how to present your case effectively. Be prepared to answer questions about the accident, your injuries, and the impact on your life.
The adjudicator will issue a written decision outlining their findings. If the decision is in your favor, the insurer will be required to pay the approved benefits.
Additional Options
If the LAT decision is unfavourable, you may have the right to appeal to the Superior Court of Justice. This is a complex legal process, and consulting with your lawyer is crucial before taking this step.
Tips for a Successful AB Claim
- Seek medical attention immediately after the accident: Documenting your injuries from the outset strengthens your claim.
- Keep detailed records: Maintain copies of all medical bills, treatment receipts, and communication with the insurer.
- Meet deadlines: The AABS has strict timelines for filing applications and appeals. Don’t miss these deadlines.
- Be honest and transparent: Provide accurate information to your doctor, lawyer, and the insurance company.
- Stay patient: The AB appeals process can take time. Be persistent and follow your lawyer’s guidance.
Don’t Be Afraid to Fight for What’s Right
A denied AB claim can be stressful, but you don’t have to navigate this alone. By understanding your rights, gathering evidence, and potentially seeking legal help, you can increase your chances of a successful appeal and receive the benefits you deserve to recover from your accident.