Dealing with Denied ICBC Claims

October 23, 2015

When you have a motor vehicle accident, you expect the insurance to provide protections and coverage under the terms of the insurance policy.  You may be counting on money coming in from the claim to cover your expenses while you are unable to work because of your injuries, including paying for out-of-pocket medical expenses and rehabilitation services. Unfortunately, things don’t always go smoothly and some insurance claims are denied. Spraggs & Co. Injury lawyers may be able to help prevent your claim being denied, or assist you to remedy the situation if your claim is denied.

Common Reasons for Claim Denial

There are many possible reasons why the Insurance Corporation British Columbia (ICBC) may deny your insurance claim. It is possible that the required forms were not completed properly, that there was alleged misrepresentation, pre-accident or post-accident health issues, or your claim could have already reached the statutory maximum payable. As well, there is always the possibility of a missed deadline, which you cannot overcome except in rare circumstances. You may also be denied if you have failed to pay your insurance premiums, meaning your insurance has lapsed, or if you have failed to notify ICBC of a new vehicle or address within the specified time. ICBC may also deny your claim if it believes that you did something to void the policy coverage.

Missed Deadlines, Failure to Complete or Improperly Completed Forms

After an accident, you must give ICBC written notice that you were in an accident within 30 days. Within 90 days of the accident you must complete a copy of the ICBC’s CL22 – Insurance Claim Application Form. Under s. 97 of the Insurance (Vehicle) Regulation (the Regulation) ICBC does not have to pay benefits where those deadlines are not met if the delay caused ICBC prejudice or harm.

Similarly, under s. 98 of the Regulation, ICBC may request medical certificates detailing the “nature and extent” of the injuries as well as “the treatment, current condition and prognosis of the injury.” Failure to comply by not completing these forms may lead to a denial of benefits, but furnishing these properly completed forms in a timely manner will normally lead to a reinstatement of benefits.

Alleged Misrepresentation and Voiding Coverage

Under s. 75 of the Insurance (Vehicle) Act (the Act), all claims are invalid and the right of an applicant to insurance money is forfeited if the applicant, to the prejudice of the insurer, falsely describes the vehicle or knowingly misrepresents a fact required in an application. ICBC can deny a claim for fraud or if the claimant willfully makes a false statement with respect to the claim. For example, the insurer may believe that the injuries are made up or exaggerated because the medical records don’t indicate an injury. ICBC may also deny a claim where treatment is delayed, using the argument that people who are genuinely hurt usually get medical treatment right away.

ICBC may void policy coverage if there was willful damage or illegal activity at the time of the accident (e.g., drunk driving, using the vehicle in a robbery, allowing an unlicensed driver to use the vehicle).

In cases where a misrepresentation is minor or inadvertent or with little prejudice to ICBC, benefits may be reinstated. Section 19 of the Act allows for statutory relief in those cases where the forfeiture is inequitable.

Pre-Accident or Post-Accident Health Issues

Sometimes a claim is denied because ICBC believes that the injury was caused by a medical condition that either existed prior to the accident or that developed after the accident due to an unrelated event. This argument is more likely to surface if you did not get treatment immediately after the accident. While ICBC may take this position, it is not necessarily clear whether the injury was incurred from the accident or before or after it. If the matter goes to court, the courts apply a test to determine whether there is a connection with the accident and the injuries, such as in Hamo v ICBC, 2007. The question asked is: did the motor vehicle accident “cause or materially contribute” to the condition? Determining whether the accident materially contributed to your injuries takes careful analysis of the medical records and similar cases, particularly in chronic pain cases. You may face a situation where an accident worsens or aggravates a pre-existing injury or condition.

Statutory Maximums

While no-fault accident benefits provide for compensation for medical treatment, rehabilitation, wage loss and loss of homemaking, each of these benefits has a statutorily defined maximum. Payment of further benefits could be denied if you have reached the statutory maximum on a particular benefit. For example, wage loss benefits and loss for homemakers are subject to limits under sections 80 and 84 of the Regulation.

Medical and rehabilitation benefits are defined by s. 88 of the Regulation and provide coverage for all “reasonable expenses incurred” by you as a result of your injury for “necessary” medical services. It may be challenging at times to argue that certain expenses are reasonable and necessary, which is where legal representation can help significantly. Total medical and rehabilitation benefits are subject to a limit of $150,000 under the Regulation’s Schedule 3 section 3(2),

Appeals Process

If you believe that an insurance company has not conducted itself in good faith, legal recourse is available. This is because the law has embraced the proposition that parties to an insurance contract owe the other an “implied contractual obligation of good faith and fair dealing” (McDonald v ICBC, 2012).

To begin, you could contact the insurance adjuster or the adjuster’s manager to request a review of the decision. This remedy is particularly effective if you have new information or records substantiating why the decision should be changed that were not available or submitted when you initially applied for the benefit.

When to Seek an ICBC Claims Lawyer

If ICBC continues to deny your claim, legal representation can make a real difference in its success. The denial could be legitimate, easily cleared up or it could be a sign of “bad faith” by ICBC. If you believe that the insurer is not living up to its obligation and is unethically refusing to pay your claim, contact our ICBC lawyers serving Surrey and surrounding areas of the Lower Mainland. The process and reasons why ICBC denies claims can be complicated and an experienced personal injury lawyer may be able to resolve matters on your behalf.

Contact personal injury and ICBC lawyers at Spraggs & Co. today for a free consultation. We serve clients in Langley, Maple Ridge, Coquitlam, Surrey and surrounding areas of the Lower Mainland. We can be reached online or at 604-464-3333 or 1-866-939-3339.

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