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Navigating the Auto Injury Claims Process

Navigating the Auto Injury Claims Process

Posted by Steve Jones

Tue, Jan 27, 2015

The claims process for an auto accident can be confusing. You’re upset about it to begin with, but if you are injured, it adds a whole new level of complexity. Knowing what you need to do and what you can expect can relieve some of the emotional and mental strain.

Here’s how the claims process works:

  • How do I get started? As soon after the accident as possible, or within 7 days, contact your insurance broker. If you are injured seriously enough that you can’t contact the broker yourself, such as with traumatic brain injury, someone should contact them on your behalf.

The insurer will then send you an “Application for Accident Benefits” package, which contains every form you might need to process your claim. Depending on the severity of your injuries and other circumstances, you may or may not need to submit every form in the packet.

  • Who do I send a claim to? If you were a driver, send the claim to your insurer. If you were a passenger in a vehicle, send the claim to the driver’s insurer. If you were a pedestrian, send the claim to the insurer of the vehicle that hit you.
  • What kinds of injuries are eligible for benefits? There are 3 categories of injuries in Ontario. Each type of injury has its own set of rules for benefits available and procedures you must take to claim them. For all of them, treatment must be “necessary and reasonable.” Also if you decide not to participate in “necessary and reasonable” treatment, the insurer may deny your claim and benefits will cease. The injury categories are:

Minor injuries, such as cuts, bruises, sprains, strains and abrasions

Catastrophic injuries, such as amputation, spinal cord injury and traumatic brain injury

Non-Minor injury, which is everything in between, such as broken bones and internal organ damage

  • Do I need prior approval for treatment for my injuries? For minor injuries, your health care practitioner (HCP), such as a doctor, chiropractor or physiotherapist, can begin immediate treatment without prior approval from the insurer. For both catastrophic and non-minor injuries, your HCP will submit a “Treatment and Assessment Plan” with a description of your injuries, any resulting disabilities, and a list of all treatments and their costs.

Of course, if your injuries are severe, you will be taken to the hospital immediately for initial treatment. You will not have to wait for your insurer to sign off on life-saving care.

In many cases of severe injury the insurer will require a 2nd opinion, to be given by their own doctors. You will have to comply with their request in order to continue receiving benefits, but if their doctor’s decision is unfavorable, you do have some recourse with the Financial Services Commission of Ontario (FSCO). See #x below.

  • What happens if I can’t work or take care of myself after the accident? If your injuries are severe enough that you cannot work, you can get partial income replacement benefits. See our article from January 20, 2015.

If you need help bathing, dressing, toileting, or feeding after an auto injury, insurance will reimburse you for the costs of personal care services. This is an important benefit, because many injuries, from broken bones to spinal cord injuries, require a long, extensive rehabilitation, and some are permanent and will require an entirely new way of living. Auto insurance in Ontario provides for reimbursement of personal care services in a long term care facility, a chronic care hospital, or in your home, depending on your needs.

Prior to November 2014, if you had a family member who had to quit their job to become your caregiver, they could receive a subsidy for lost wages. That subsidy is no longer available, so your best course of action is to hire a professional aide so your loved one can continue working.

A registered nurse or occupational therapist can assess how much assistance you need, and submit a form to apply for reimbursement for an aide or personal support worker (PSW). Once the form is submitted, the insurer has 10 days to respond, and once they have approved the claim, they must reimburse you within 30 days.

  • What if my insurer denies my claim or I am not satisfied with their offer? If you have a dispute with your insurer, first talk to your insurance company representative or adjuster. If you cannot come to a resolution with them, new regulations from Bill 15, Fighting Fraud and Reducing Auto Insurance Rates Act, of November 2014 require you to go into arbitration conducted by the FSCO. Mediation is no longer available and there is no option to go to court if the dispute is not resolved to your satisfaction.
  • Can I still hire a lawyer to help me with my claim? Yes, you can hire a lawyer to negotiate for you with your insurer, but you can no longer sue your insurer in superior Court. A Toronto area lawyer has launched a constitutional challenge to Bill 15, on the basis that it violates disabled persons’ right to be free from discrimination and restricts the public’s right to have access to the courts.

If you have been injured in an auto accident and would like to talk to a neutral but knowledgeable third party about your situation, Qualicare has experienced and qualified case managers who are happy to help. Give us a call, or click on the image below to contact us