Ontario law requires all auto insurance companies to provide specific benefits to policyholders. These requirements are set forth in the Statutory Accident Benefits Schedule (SABS). Depending on the specific facts of your car accident, you are entitled to benefits such as medical treatment costs (beyond what your other insurance covers) and income replacement benefits if you are unable to return to work right away.
Unfortunately, insurers often try to get out of their duty to pay benefits in a timely manner following a car accident. When benefits are denied, policyholders may seek assistance from the Automobile Accident Benefits Service (AABS) of the License Appeal Tribunal.
The Tribunal has the authority to review and reverse a decision to deny statutory benefits. In addition, the Tribunal can make a “special award” equal to 50% of the benefit the applicant was entitled to by law if the insurance company acted “unreasonably” in withholding or denying payment on a valid claim.
Applicant v. Aviva Insurance Canada: Insurance Denial Rejected by License Appeal Tribunal
Here is a recent illustration of how the License Appeal Tribunal functions in practice: The applicant in this case filed a claim for an income replacement benefit (IRB) from her auto insurance company following a car accident in November 2015. She was a passenger in the car at the time. The insurance company ultimately denied her claim.
Before the Tribunal, the applicant’s Ontario personal injury lawyer testified that she was employed at the time of the accident as a “general labourer” working 40 hours per week at a warehouse. Her position had substantial physical requirements, including standing and lifting boxes “non-stop” for upwards of nine hours per work-shift.
Following the accident, the applicant said she “could not return to her former job” due to extensive back pain, which limited her ability to stand continuously and carry boxes.
She also told the Tribunal that prior to the accident, she “was healthy and did not have any psychological or emotional problems.” But after hitting her head during the accident–sustaining a traumatic brain injury in the process–she started to experience serious headaches, which persist to the present. The applicant also described other symptoms of serious psychiatric trauma, including lack of sleep and recurring nightmares.
The Insurance Company Blames a Traumatic Childhood
The insurer did not dispute that the applicant was employed in the way she described. Rather, to defend its decision to deny income replacement benefits, the insurer argued that the applicant’s injuries did not arise from the car accident, but rather were the byproduct of “prior traumas in her life.”
The insurer pointed to the applicant’s childhood in Sierra Leone, where she “saw family members and neighbours get killed,” as well as to her parent’s divorce and the stress of dealing with a prior workplace accident involving her mother.
The Tribunal’s adjudicator rejected the insurance company’s attempt to deflect responsibility. The adjudicator noted that all of the available evidence showed the applicant “was healthy, worked full time and was relatively pain free” until the date of the car accident. Given that the applicant’s childhood “war experiences in Sierra Leone” were “many years ago,” the adjudicator concluded that the car accident was responsible for the applicant’s current medical impairments.
Proving IRB Eligibility
To qualify for an income replacement benefit, an applicant must suffer “from a substantial inability to perform the essential tasks of her or his employment.” In this case, the essential tasks of the applicant’s warehouse job included packing and lifting boxes, scanning and counting products, and shipping items.
The applicant presented medical testimony from multiple doctors, as well as a Disability Certificate from her chiropractor, to support her claim that she could no longer perform those tasks. According to the Disability Certificate, she suffered from “[s]prain & strain of cervical and thoracic spine, lumbar spine, [and] shoulder joint,” in addition to her headaches and insomnia.
Separately, the applicant’s psychologist diagnosed her with major depressive disorder, severe post-traumatic stress disorder, and related mental impairments. Finally, a chronic pain expert told the Tribunal that the applicant “will not be able to return to her pre-accident level of functioning at her employment” due to chronic pain syndrome.
Tribunal Underwhelmed by Insurer’s Medical Evidence
To rebut the applicant’s extensive medical evidence, the insurance company presented testimony from three experts of its own. All three argued that the applicant “does not suffer from a substantial inability to perform the essential tasks as a general labourer.”
The adjudicator did not find these experts as credible as the applicant’s doctors. For example, the insurer employed a family doctor to dispute the applicant’s claim that she suffered from chronic pain syndrome. But as the adjudicator noted, this doctor was not “an expert in the field of chronic pain.” Accordingly, the adjudicator gave only “limited weight” to his testimony.
The insurer also presented a psychologist who examined the applicant one time and concluded she did not “suffer a substantial psychological inability to perform the essential tasks of her pre-accident employment.” The problem with this testimony, the adjudicator said, was that the psychologist did not “do any kind of in depth analysis of what [the applicant] did for work.”
In fact, the psychologist admitted under cross-examination that he had no idea what the applicant’s job was before her accident.
Ultimately, the adjudicator held that the applicant was entitled to an income replacement benefit (with interest). He declined to make a special award because he said the insurer’s initial actions were not “so egregious” as to be considered unreasonable.
Were Your Ontario Statutory Accident Benefits Denied? We Can Help!
As the above case illustrates, competent medical evidence is often the key to successfully pursuing a claim for statutory accident benefits in Ontario. Insurance companies will never give you the benefit of the doubt when it comes to a medical diagnosis. When your insurer denies your SABS claim, you need an experienced Toronto personal injury lawyer by your side to help you challenge that denial before the License Appeals Tribunal.
If you are attempting to reverse your insurer’s denial of benefits following a car accident in Ontario, contact the Preszler Law Firm to schedule a free, no-obligation consultation with one of our experienced auto accident lawyers today.