Insured Victim Seeks Court Assistance After Coverage Denied

Following an automobile accident, an insured victim seeks court assistance after coverage denied, it’s natural for people to rely on their insurance providers to help them secure benefits that they may need in order to heal, rehabilitate, and get back to the life they enjoyed prior to the accident. But insurance policies can be complicated contracts, and people sometimes find they are not entitled to all of the benefits they thought they were eligible to receive. This was the situation in a recent case heard by the Supreme Court of Nova Scotia, where the court was asked to rule on an insurer’s failure to provide certain accident claims for one of their customers.

The automobile accident

The plaintiff was injured in a car accident in October 2014. She had purchased insurance through the defendant, an insurance company. While she did receive her statutory accident benefits, the insurer denied her request to be reimbursed for a medical procedure. In 2017 she responded by suing the insurer, claiming they had improperly denied her medical benefits under the policy and breached its duty of good faith in investigating her claim. Her counsel also requested that the insurer disclose its policies, procedures, and more details on how accident claims are handled and resolved. The insurer denied this request as well as any wrongdoing.

Determining the relevancy of documentation

The court referred to a 2011 decision from the Supreme Court of Nova Scotia, which states that the ultimate question is whether the material being sought has probative value with respect to a claim made in the pleadings. In this case, the action was that the insurer’s denial of the claim was “the result of the overwhelmingly inadequate handling of the claim, or the introduction of improper considerations into the claims process.” The plaintiff argued the way the insurer handled the claim must be judged against their own procedures, standards, guidelines, and policies.

The insurer’s argument

The insurer argued that the plaintiff’s claims amounted to nothing more than an allegation of bad faith, of which the materials requested are irrelevant since the claim does not reference any failure or lack of policies, etc. The court agreed that a simple assertation of bad faith is not in and of itself enough to require the disclosure of internal documents. But the court did say, “When the pleadings contain more specific allegations that the defendant did not adhere to the obligation of good faith, the insurer may be required to disclose the internal documents about its policies, procedures and guidelines for assessing claims if they are relevant to the claim” adding “The question then is whether those policies and procedures are probative with respect to a claim of bad faith when the claim neither specifically claims that there are no policies or that if there are policies that they have not been followed.”

Applying the analysis to the facts at hand

In this particular case, the plaintiff asserted that the insurer had an obligation to act in good faith, and breached that duty. The statement of claim alleges the insurer denied the claim “in an arbitrary manner without consideration of all medical evidence or a fair and equitable application of the Policy” and that they insurer allowed “a lay person(s) to interpret medical evidence while adjudicating the claim, Intact relied on the lay person(s) analysis of medical documentation and information in wrongly denying the claim.”

The court determined the allegations of the plaintiff are neither “bald” nor “boiler-plate” and are not a simple allegation of bad faith. The court noted that while the plaintiff “does not allege that (the insurer) failed to have policies or procedures or that, if it did, it failed to follow those established procedures. Without knowing what those procedures or protocols were, or if they even existed, (the plaintiff) would not know whether they had been followed.”

The court ordered the disclosure of the requested materials.

You may find yourself being aggressively pursued by your insurer or their representatives following an accident. They may try to aggressively pursue statements and documentation from you. Don’t let the adjusters of the insurance company take advantage of your situation. Additionally, there are many strict limitation periods that apply to no-fault claims and someone’s right to sue following an accident. It’s best to contact Derfel Injury Law as soon as possible following an accident to make sure you do not miss a limitation period and/or miss out on your rights to compensation altogether.

Contact Derfel Injury Law to meet the personal injury lawyers and professional legal team who will work tirelessly to achieve the best possible resolution to your accident benefits claim. Our office is conveniently located in Toronto. Call us at 416.847.3580 to schedule a visit at the individual office closest to you or contact us online.