Under Ontario’s No Fault Auto Insurance Scheme, injured parties who require treatment or income replacement benefits must apply to their own insurance company for these benefits. This system works relatively well until such time as the insurance company and the injured party disagree about what benefits the insurance company should pay for (or continue to pay).

Opposing the decision of an insurer to pay or continue to pay for a benefit can be overwhelming for injured parties. The process can be lengthy and frustrating. The first step involves obtaining a professional (usually medical) opinion confirming that the claimant meets the criteria to qualify for payment of the benefit. Sometimes this can be obtained from a family doctor or a treatment provider regarding the specific benefit. It can be important that the professional providing the opinion understands the criteria for the benefit.

If the insurer does not change their decision regarding entitlement to the benefit upon receipt and review of the additional opinion evidence, then an application will need to be brought to the License Appeal Tribunal (LAT) in order to dispute the denial. Applications to the LAT must be commenced within two years of the denial of the benefit in question. Once the written application is submitted, the LAT schedules a case conference which is held by phone and typically involves settlement negotiations. If the negotiations do not result in settlement of the issues, then procedural issues with respect to the LAT hearing are addressed including timing of productions, submissions and the hearing date itself. It can take more than a year to learn the outcome of a dispute brought before the LAT. Since some benefits are only available for up to 5 years following the motor vehicle accident in question, this means LAT applications should be initiated as soon as possible in come cases, to prevent a decision in the claimants’ favour from coming too late for them to actually benefit from the treatment the LAT adjudicator found them to be entitled to.

LAT hearings can be conducted in writing, or by zoom, or a hybrid of the two. There is no provision for a successful party at the LAT to have the losing party pay for the legal fees incurred in pursuing the application. In theory, a claimant could pursue the LAT application by themselves, without counsel, but many are in no condition due to their accident related injuries to pursue this kind of dispute resolution on their own. During the case conference as well as the entire LAT process, the insurer is usually interested in settling the whole accident benefit file including all future benefits to which the claimant may be entitled. Most claimants require legal advice to determine what a fair amount would be for this kind of settlement including the impact such a settlement can have on their claim against the at fault driver.

If you or a loved one has been in a car accident, either as a driver, passenger, cyclist or pedestrian and you are wondering whether your accident benefits have been unfairly denied, don’t hesitate to contact us for a free consultation.

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