Insurance Examination (IE)

Most often our clients ask us if they have to attend the Insurance Examinations and why? We advise them to attend the examination based on the specifics of their cases. If you are injured in a car accident, you might receive a notice from your insurer that requires you to attend an examination in order to determine your eligibility for receiving or continuing your accident benefits such as treatment or weekly benefits.

Insurers send Notice of Examinations to the claimants to attend the examination when they do not approve the Form OCF-18. Form OCF-18 is Assessment and Treatment Plan, which is completed by you and your physician that outlines the types and lengths of treatments you need to recover from as a result of your accident.

You might wonder why would insurance companies deny your treatments that were assessed and planned by a qualified health physician. The reality is that insurers want to collect their own evidence including medical reports when determining eligibility for benefits that fall outside the Minor Injury Guideline. Now it is up to the injured person to prove that their injuries fall outside this Guideline and provide medical and other evidence to get the benefits.

Statutory Accident Benefits Schedule (SABS) requires you to attend the examination requested under s.44.1. When an insurer asks the insured person for a medical examination, the insurer is also responsible to pay for the examination fee, transportation expense, and interpretation if needed.

If you don’t attend the examination or if you think it is not a reasonable request, then there are consequences. Your insurer will not be able to determine your benefits or they will discontinue the benefits you are receiving. In addition, you will not be able to appeal your insurer’s denial of your benefits unless the arbitrator decides in your favor.

Insurers have tried to stop applicants who did not attend the insurance examination, from proceeding to arbitrations, but they have not always been successful. In Larry Ward and State Farm Mutual Automobile Insurance Company [FSCO A14-010161] , the arbitrator decided in favour of the insured person despite his lack of cooperation in attending the insurance examination. In his decision, the arbitrator stressed the importance of giving adequate information in the notice of examination such as providing medical and other reasons for need of such examination and that the examination itself should reasonably be necessary as stated in law. Arbitrator emphasized on adherence to the procedural fairness and giving enough information to the applicant to make informed decision.

At Noohi Law we ensure to protect our clients from unfair and unreasonable insurance examinations. We have been working with different qualified health practitioners to provide accurate and unbiased medical evidence to insurers to obtain the benefits our clients need at their most difficult time to recover from their accident injuries. If you have been involved in a car accident and if you have any questions, please contact Noohi Law at 416-907-7364 to schedule a free consultation meeting.

References:

O. Reg. 34/10: Statutory Accident Benefits Schedule (SABS)- Effective September 1, 2010

SABS- s.44.1

SABS- s.44.9 (2)(iii)

SABS- s.44.5

SABS s.55. 1(2)

Decision of Financial Service Commission of Ontario on Larry Ward and State Farm Mutual Automobile Insurance Company [FSCO A14-010161]

Rules of Civil Procedure Rule 4.1.01(1)