Changes to the Process for Resolving Accident Benefit Claim Disputes

Motor vehicle accidents occur frequently on the roads of Ontario, and many of these result in serious injury and correspondingly, in personal injury claims. In addition to filing a lawsuit against the negligent driver, Ontarians suffering from injuries have the option of making a claim for accident benefits with their own vehicle insurance company pursuant to the Statutory Accident Benefits Schedule (SABS).  Also referred to as “no-fault accident benefits”, SABS is a regulation under the Ontario Insurance Act that specifies which statutory benefits are available to anyone injured in a motor vehicle accident.

Under SABS, an injured person can be compensated for their incurred expenses, including medical treatment, care provisions and income replacement. These benefits are needed by accident victims during the recovery period following a collision that caused their injury. Anyone who was injured in a motor vehicle accident is eligible, including pedestrians, cyclists, vehicle drivers and passengers, motorcyclists and riders of recreational vehicles such as snowmobiles.

There are three major categories of injuries under SABS: minor injury guideline (MIG), catastrophic impairment claims (CAT) and non-catastrophic injury claims. The severity of a person’s injuries dictates how much compensation they are eligible to receive from their accident claim.  A person who suffers a “predominantly” minor injury is limited to a maximum of $3,500 in medical and rehabilitation benefits and is not eligible for attendant care benefits. A person suffering a catastrophic impairment injury is currently eligible for significantly greater benefits including up to $1 million payable over a lifetime for medical and rehabilitation benefits and $1 million for attendant care benefits.

Although injured persons in Ontario are entitled to statutory accident benefits, accident claims are sometimes disputed by the insurer, and there are upcoming changes to the process by which Ontarians can file a claim when their benefits are disputed.

The Old Process: Resolving Insurance disputes through FSCO

The Financial Services Commission of Ontario (FSCO) is the government body that handled insurance disputes up to April 2016. The FSCO is responsible for regulating the insurance sector, loan and trust companies, credit unions and pension plans, and also for resolving injury claim disputes.  

Any person having a grievance with their vehicle insurance company concerning their claim for accident benefits was able to have their complaint resolved by FSCO.  FSCO provides a service for registering your complaint and resolving your dispute by means of mediation or arbitration.  Particularly for insurance disputes that must be solved in arbitration, representation by a personal injury lawyer is recommended (as you are going up against a highly experienced insurance attorney), but not mandatory.

The New Process: The Licence Appeal Tribunal

Beginning April 1, 2016, the FSCO will no longer handle insurance disputes. However, any applications already assigned an arbitration number with FSCO will be completed under the ‘old’ system.

The Licence Appeal Tribunal (LAT) will now adjudicate all motor vehicle accident disputes through a system called the Automobile Accident Benefits Services or AABS. There will be a new set of rules under the new dispute process. Under AABS, any person who is injured in an accident or the insurance company can submit an application to AABS if there is a dispute about the injured person’s right to accident benefits or disagreement over the amount of benefits.

The four steps to file an application with AABS are:

1. Complete an Application Form.
2. Provide the other party or their representative with a copy of the completed application.
3. Complete a Certificate of Service Form.
4. Pay the required application fee.

Applications can be filed by mail, fax or in person. A party may be required to file a response if they receive a completed AABS application form and/or if they receive a Notice of Application from AABS with instructions to file a response. Responses can be filed by completing a Response Form and a Certificate of Service. The party must also submit a copy of the completed response to the other party of their representative. The AABS will make every attempt to resolve the dispute between the parties and conclude the matter fairly.

Benefits and Concerns

The new system has several advantages. The application forms have been simplified. Eventually, you will be able to file electronically, which is expected to speed up the application processing time. There will be shorter timelines for scheduling case conferences and hearings and the completion timeline for most cases will be around six months.

As well as some benefits, there are also a few concerns. Under the former process, applications for accident benefits were free. Under LAT, there is a filing fee of $100. LAT adjudicators may, at least initially, lack the experience in accident benefits legislation as they are not subject to the same case law as under FSCO. Finally, there is a concern that LAT will not be able to handle the typical caseload of over 10,000 cases per month even with the increase in staff.

The new process for insurance disputes will certainly have an impact on how Ontarians go about resolving their accident benefits grievances. The hope is that the new process will turn out to be an improvement.

In the event of a dispute over an injury claim or owed benefits with your insurance company, the experienced insurance lawyers at Injury Lawyers of Ontario (ILO) can provide expert advice and representation to optimize your chance of successful resolution of your case.  Call an ILO office in your community today to find out how we can assist you in obtaining your owed benefits.