The Denied Files

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Single mom’s coverage cut off – insurer forced to reinstate benefits and pay a penalty

Jennifer was crossing the street at a green light on her way to work when suddenly and without warning she was struck by a vehicle. Jennifer rolled on the hood of the vehicle, hit her head, and was badly injured.

The collision completely changed Jennifer’s life. She was no longer able to work in any capacity due to the pain, injuries, and psychological trauma she experienced after being struck by a vehicle. Jennifer was a single mother and relied on an income to support her family. She was not able to work after the accident and her insurance company, RBC, paid her a percentage of her income in the form of weekly “income replacement benefits”. RBC paid these benefits steadily and then terminated them without warning. RBC argued that Jennifer was still able to work and that her psychological issues were a result of her difficult childhood and that the collision had nothing to do with it. RBC sent Jennifer to several long and painful assessments. RBC questioned her eligibility to receive benefits even though the results of several assessments showed Jennifer’s injuries were caused by the accident.

In the end, it was found that Jennifer took pride in caring for her children and would work to support her family if she could. Jennifer was awarded the income replacement benefits she was entitled to and was provided with a monetary award to compensate her for RBC’s bad behaviour in unreasonably refusing to pay her the benefits she was entitled to.

After the accident, Michael can’t work or even walk – and yet his insurer tries to cut him off

Michael was involved in a motor vehicle collision and sustained serious injuries to his neck, arm, back, jaw, and shoulder that required a great deal of treatment. Michael felt his life was shattered by the collision as he could no longer work or engage in any of his hobbies. Many doctors and medical professionals agreed that Michael could not walk, stand, or move without experiencing pain. Michael’s insurance company, Wawanesa, paid him the weekly income replacement benefits he was entitled to but then without any warning suddenly terminated his benefits. As if that wasn’t bad enough, Wawanesa also refused to reimburse Michael for the treatment expenses he incurred for his injuries.

In the end, it was found that Michael was unable to work in any capacity whatsoever because of his injuries and he was entitled to have his medical expenses paid for. Michael was also given a special monetary award to compensate for Wawanesa’s unreasonable behaviour.

How low can they go? insurer tries to weasel out of covering funeral expenses

Elsa’s elderly husband, Chuck, was out for an evening walk when he violently fell to the ground after a motor vehicle backed up and hit him. Chuck passed away a few days after the fall due to his injuries. Elsa asked Chuck’s insurance company, Wawanesa, to pay for Chuck’s funeral expenses. Elsa also asked for the payment of other benefits related to her husband’s death.  Wawanesa refused to pay Elsa any money and argued her husband’s fall was not even caused by the vehicle hitting him.

In the end, Wawanesa was ordered to pay funeral expenses, several monetary benefits, and a lump sum monetary award to Elsa for failing to treat her in a fair and reasonable manner.

Car runs a red light, t-bones another– Surely, an open and shut case? Nope, Insurer denies coverage

Vlad was driving his car through an intersection when he was t-boned by a car that ran a red light. Vlad was seriously injured. At the time of the collision, Vlad was working and taking night classes. Because of Vlad’s injuries to his shoulder, neck, and back, he missed several classes and could no longer work.

Vlad required several forms of medical treatment for his injuries. Even though Vlad was unable to work, his insurance company, Wawanesa, did not pay him any income replacement benefits, refused to pay for his medical treatment, and even refused to pay for the cost of a disability certificate. Vlad was unable to attend treatment, experienced a great deal of pain, and fell on financial hardship.

In the end, Wawanesa was ordered to pay Vlad income replacement benefits, reimburse him for his medical expenses, pay for his disability certificate, and pay him lump sum special award for their unreasonable behavior in withholding benefits he was entitled to.

Insurer ordered to reimburse accident victim’s family for care provided

Debbie was involved in a serious car crash that caused her to develop a seizure disorder and suffer several injuries to her head, back, neck, ribs, and spleen. At the time of the collision Debbie was a stay-at-home mother responsible for caring for her children and family. Debbie was badly injured and was no longer able to perform household tasks or care for her children. Debbie’s family helped her by providing her care during her very difficult recovery. Debbie’s insurance company, Wawanesa, only paid Debbie a limited amount of money to cover her needs and claimed that Debbie was not injured enough to qualify for increased benefits. To make matters worse, Wawanesa did not provide Debbie with essential information about the benefits that she was entitled to under her insurance policy.

In the end, an arbitrator ruled that Debbie’s family was entitled to be compensated for the care they provided. Also, Debbie was entitled to have housekeeping services paid for and she was given a monetary lump sum award to compensate her for Wawanesa’s bad behaviour.

Insurer tries to deny responsibility for critically injured driver

Back in 2006, Eckhart Schmitz is driving along, minding his own business, when he gets hit by a car driven by Ervin Baonyi. Unfortunately, this was no fender-bender.

In this crash, Eckhart is badly injured and he needs a lot of treatment to heal properly. He sues Mr. Baonyi to help recover some of those costs, but there’s a problem: Mr. Baonyi’s insurance is limited to $1 million and Eckhart’s claim is much bigger than that.

Fortunately, Eckhart has his own insurance policy to rely on — or so he thinks!!

Like most drivers, when Eckhart purchased his car insurance, he bought extra protection: an insurance endorsement called “Family Protection” coverage. Most people with car insurance have the same Family Protection coverage. Check your own policy to make sure! Keep an eye out, as your insurer may list it as “OPCF 44R” in official insurance speak.

Family Protection is supposed to help in situations like this, when an at-fault driver doesn’t carry enough insurance to cover all the related losses. With Family Protection coverage, your own insurance company is supposed to step in and provide the difference required to pay for your treatment (up to the value of your insurance coverage).

But no, Lombard insurance had other ideas. They tried to deny his clear-cut claim, saying that Eckhart didn’t file the claim quickly enough – he was outside the “limitation period,” they said.

Fortunately, the Court of Appeal got it right and made Lombard pay out under the Family Protection coverage. After all, that’s what it’s there for!

Insurer tries to hide behind uncertainty; special awards ensue

Ever had a nagging injury that you just can’t get rid of? Worse yet, have you ever been unable to pinpoint what the specific problem is?

Well, for Ted, this was exactly the case following a car accident.

Given that Ted couldn’t work due to his injuries, he was forced to rely on accident benefits provided by his insurer to ease the financial burdens associated with his accident.

His insurer, Algoma Mutual Insurance, required Ted to attend medical assessments to determine whether or not he should qualify for weekly income replacement benefits. No big deal, right?

The problem: the medical professionals hired by Algoma couldn’t figure out what was wrong with Ted either!

Sure enough, Algoma figured this meant they didn’t have to compensate Ted in his greatest time of need – they refused payment of his income replacement benefits.

Thankfully, the Financial Services Commission of Ontario (“FSCO”) Arbitration Board was on to Algoma’s antics, concluding that just because you can’t pinpoint the source of someone’s injury, that doesn’t mean you can avoid your obligation to pay.

So what’s the takeaway? FSCO prefers to focus on whether you’re able to complete the essential tasks required for your employment, not the reasons why you can or can’t do them.

Ted was finally able to focus on recovery and not on the work he couldn’t do. Thanks for getting it right, FSCO!

24/7 means 24/7!

Tyrone was in a terrible car accident. In fact, he was left a paraplegic as a result. Fortunately for Tyrone, he had a loving mother who took a leave of absence from her job to provide him the 24/7 care he required.

Her life’s focus was now taking care of her injured son. Sure, the hours were 24/7 instead of her usual 9-5, but she wanted to give him the best care possible.

So what went wrong? Gore Mutual Insurance Company took the position that they only had to pay for the level of employment she left to take care of Tyrone, not the level of care she actually provides!

Tyrone and his mother felt this was unfair, and we don’t blame them! If they had opted for third-party attendant care, someone would have been paid to be there 24/7, because that’s the level of care Tyrone needs. Just because his mother took it upon herself to provide these services, that doesn’t mean the full-time nature of the work should go uncompensated.

Luckily, the Court of Appeal looked at the circumstances more logically than Gore, focusing on the level of care and not the source of care.

Now Tyrone’s mother can take care of him as only she can and she’s being compensated fairly for it. Now that’s justice!