The insurance claims adjuster process for accident benefits

Alex Mlynek
by Alex Mlynek November 22, 2019 / No Comments

If you’ve been injured in an automobile accident, then you may be entitled to benefits that could cover such costs as physiotherapy, income replacement, or attendant care. In Ontario, we call them statutory accident benefits

If a person dies in this type of accident, then their loved ones may receive to death and funeral benefits. Which is why it’s important everyone knows about accident benefits.

The person who decides what kind of benefits the insurance company will pay is a type of insurance adjuster known as a bodily injury adjuster, explains Sivan Tumarkin, a partner at Samfiru Tumarkin LLP who leads the firm’s long-term disability and personal injury law practice group. 

Accident benefits is a minimum requirement with all Ontario car insurance policies. 

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The process of the insurance claims adjuster

After an accident, the insurance claims adjuster assigned to your case will ask you and your medical care team to fill out forms detailing your injury. They also want to see your full treatment plan. The claims adjuster will then review all of the paperwork and documentation, such as X-ray imaging and hospital records. They may also consult with the insurance company’s own medical professionals. 

Then, the insurance claims adjuster will make a determination about the type of benefits the company will pay you, which is often based on the injury category they place you in. Finally, they either sign off on whether the treatment plan suggested by your medical team is reasonable and necessary or not, says Meghan Walker, an associate with Will Davidson LLP, a law firm that focuses on personal injury and insurance defence.  

The type of benefits available to you are based on several factors, including how severe the adjuster determines your injuries to be. In Ontario, for example, there are 3 categories of injury.

Minor injuries

An injury can fall under the minor injury guidelines — something like a soft tissue injury (think bruises, strains, and sprains)

Non-catastrophic

A non-catastrophic injury is something a little more severe, like a concussion or a broken bone. 

Catastrophic

A catastrophic injury is something that’s life altering, like paralysis. 

Disputing your accident benefits amount

If you disagree with the claims adjuster’s decision, what happens next depends upon where you live. In Ontario, for instance, you would file an application for review at the licence appeal tribunal (LAT). More specifically, in a section of the LAT called the automobile accident benefits service. 

The adjuster is a part of the team for the first stage of this process known as the case conference, says Tumarkin. The conference usually happens over the phone. “It’s a session of trying to resolve the dispute,” he explains. “The adjudicator doesn’t make any decisions in terms of ‘you’re right, you’re wrong,’ they try to narrow down the issue and mediate between the parties.” If there is no resolution, then there is a hearing where evidence is presented and an adjudicator will make a final determination.

The Bottom Line

Now that you have some sense of what a claims adjuster does in terms of accident benefits, it will hopefully help you navigate the situation from an informed perspective if, unfortunately, you become hurt in an automobile accident. 

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