You were hurt in a car accident and did what you were told: you notified your insurer, filed the accident benefits application, and started treatment. Then a letter arrived. The insurer is not approving the treatment plan, or has decided you are no longer entitled to income replacement, or has concluded that your injuries fall within the minor injury category and that your benefits are capped. It reads as final. It is not.
Accident benefits do not depend on fault
In Ontario, anyone injured in a car accident is entitled to statutory accident benefits from their own insurer, or in some cases from the insurer of the vehicle involved, regardless of who caused the collision. The benefits are set out in a regulation and include medical and rehabilitation expenses, attendant care, income replacement or non-earner benefits, and other costs depending on the circumstances. We have written separately about how accident benefits and a tort claim run in parallel.
Because the benefits are statutory, the insurer’s decisions about them are governed by rules, and those decisions can be challenged.
The most common reasons for denial
- Treatment plans. Each proposed course of treatment is submitted by your provider on a prescribed form. The insurer can approve it, deny it, or refer you to an assessment by a practitioner of its choosing before deciding. Denials are often based on that assessment concluding the treatment is not reasonable and necessary.
- Minor injury classification. If the insurer decides your injuries are limited to sprains, strains, whiplash and similar soft tissue injuries, it will treat them as falling within the Minor Injury Guideline, which caps medical and rehabilitation benefits at a modest fixed amount. Escaping that category requires evidence that your injury is not minor, or that a pre-existing condition documented before the accident would prevent recovery within the guideline. Our post on the Minor Injury Guideline explains this in detail.
- Income replacement. Insurers regularly stop income replacement benefits after an insurer’s examination concludes that you can return to your pre-accident employment, or, after a period, to any employment for which you are reasonably suited.
- Late applications and missing forms. Benefits can be delayed or refused where the application was not submitted within the required time, or where a form was incomplete. These are often fixable, but they need attention.
Read the denial letter carefully
A denial must set out the reason and tell you that you have the right to dispute it. Note the date. Your right to dispute the denial at the Licence Appeal Tribunal is subject to a two-year limitation period that runs from the insurer’s refusal. Missing it is generally fatal to that particular dispute, although later denials of later claims start their own clocks.
Insurer examinations
Before denying most benefits, the insurer must send you to an examination by a health professional it selects. You are required to attend, and refusing without a proper reason can itself lead to benefits being suspended. You are also entitled to a copy of the report. We have written about what an insurer’s examination involves, including what to expect and how to prepare.
Disputing the denial at the Licence Appeal Tribunal
Accident benefits disputes in Ontario are decided by the Licence Appeal Tribunal, not the courts. The process starts with an application, followed by a case conference where the issues are narrowed and settlement is explored. If the matter does not resolve, it proceeds to a hearing, which may be in writing, by video, or in person depending on the issues.
The Tribunal decides on the evidence. That means your treating practitioners’ records, the insurer’s examination reports, any independent assessments you obtain, and your own testimony about how the injury affects you. Cases are often won or lost on the quality and consistency of the medical record, which is why gaps in treatment and unexplained inconsistencies matter.
What to do while the dispute is running
Keep treating. Stopping treatment because the insurer will not pay for it hurts both your recovery and your claim. Ask your providers about options, including coverage through extended health benefits or provincial programs, and keep every receipt, since expenses paid out of pocket can be claimed.
Keep a record of how the injury affects your day-to-day life: work, sleep, household tasks, care for children. Contemporaneous notes carry more weight than recollection years later.
Do not sign a full and final settlement of your accident benefits without advice. Settling benefits early, particularly before the extent of your recovery is known, can close off entitlements you would otherwise have had for years.
How we can help
At Kabir & Alam, we review accident benefits denials, deal with the insurer on your behalf, and represent injured people at the Licence Appeal Tribunal. If you have received a denial, read more about our motor vehicle accident practice or book a consultation with us, and bring the denial letter with you.
This post is general information about Ontario personal injury law and is not legal advice. Every case turns on its own facts. Speak with a lawyer about your situation before making decisions.