Insurance Company Denied Catastrophic Injury Benefits After Disputed Medical Report

An Ontario woman was denied catastrophic injury benefits after an insurance company’s medical report allegedly misrepresented the findings of several specialists. She challenged the decision and was ultimately recognized as catastrophically impaired, giving her access to substantially greater accident benefits.

Insurance and personal injury lawyer Sivan Tumarkin discussed the case on Toronto’s AM640, explaining how insurer-selected medical assessments can affect injury claims and why injured people shouldn’t automatically accept an insurance company’s decision.

Ontario Woman Denied Catastrophic Injury Benefits After Medical Report

The case involved a woman who suffered devastating injuries in a car accident and sought recognition as catastrophically impaired under Ontario’s accident benefits system.

Her insurance company relied on a summary report prepared by a Toronto family physician who reviewed medical assessments from specialists, including neurological experts.

The insurer used that report to determine that the woman’s injuries did not qualify as catastrophic, limiting the accident benefits available to her.

However, concerns emerged that the physician’s summary had distorted or omitted important findings from the specialists’ reports.

Speaking on radio station 640 Toronto, Sivan explained that the disputed report presented a more favourable picture for the insurance company than the underlying medical evidence supported.

Woman Successfully Challenges Insurer’s Decision

The woman’s challenge succeeded. The disputed medical report was undermined, and she was ultimately recognized as catastrophically impaired.

That decision made a significant difference to the benefits available for her injuries and recovery.

Catastrophic impairment is an important designation in Ontario’s accident benefits system. It can provide access to substantially higher medical, rehabilitation and attendant care benefits than those available for non-catastrophic injuries.

Sivan emphasized that these benefits aren’t simply extra payments. They’re financial support that seriously injured people need for treatment, rehabilitation and daily living.

The case demonstrates why challenging an insurer’s assessment can make an enormous difference to an injured person’s financial security and recovery.

Can Insurance Companies Rely on Misleading Medical Reports?

Insurance companies frequently rely on medical assessments to determine whether an injured person qualifies for benefits and how much support they should receive.

But an insurer’s medical report can be challenged, particularly when it overlooks important evidence, misrepresents a specialist’s findings or reaches conclusions that aren’t supported by the medical records.

Sivan explained that some physicians are paid by insurance companies to assess claims or review medical evidence. Their opinions can have a major influence on whether benefits are approved or denied.

Having previously represented insurance companies himself, Sivan understands how insurers evaluate claims and the role medical assessments play in those decisions.

He also described how he examines the credibility and court history of physicians retained by insurers, including whether judges have criticized their opinions in previous cases.

An insurance company’s medical report can be disputed. Your treating doctors’ findings, specialist assessments and complete medical history can all be important when challenging a denial.

What Happens When an Insurer Denies Accident Benefits?

A denied or reduced accident benefits claim can leave an injured person struggling to pay for treatment, rehabilitation and everyday expenses.

Depending on the injuries and coverage, Ontario accident benefits can include:

• Medical and rehabilitation benefits: Funding for eligible treatment, therapy and rehabilitation services.
• Income replacement benefits: Financial support when accident-related injuries prevent you from working.
• Attendant care benefits: Assistance with personal care when injuries affect your ability to manage daily activities.
• Other accident benefits: Additional support available under the policy and applicable Ontario accident benefits rules.

If your insurer refuses to recognize the severity of your injuries, you could lose access to substantial financial support.

That’s why it’s important to challenge an incorrect assessment rather than assume the insurance company’s decision is final.

What Should You Do if Your Accident Benefits Are Denied?

If your insurance company denies benefits or disputes the severity of your injuries:

1. Get the insurer’s decision in writing. Understand which benefits were denied and the reasons provided.
2. Keep your medical records. Preserve reports from your doctors, specialists and rehabilitation providers.
3. Request the medical assessments relied on by the insurer. These reports may reveal important differences between the insurer’s conclusions and your treating physicians’ findings.
4. Continue following your treatment plan. Document how your injuries affect your ability to work and manage everyday activities.
5. Speak with a personal injury lawyer promptly. Find out how to challenge the denial and protect your right to compensation before applicable deadlines expire.

Denied Accident Benefits? Get Legal Help

If you’ve been seriously injured in an Ontario car accident and your insurance company has denied or reduced your benefits, the personal injury lawyers at Samfiru Tumarkin LLP can help you challenge the decision and pursue the compensation you’re owed.

Our firm offers free consultations for personal injury claims and works on a contingency fee basis — you don’t pay legal fees unless we win your case.

Don’t let an insurance company’s decision determine your future. Contact us today or call 1-855-821-5900.