In the province of Ontario, individuals injured as a result of a motor vehicle accident can claim no fault benefits through their accident benefits carrier. Available benefits include income replacement benefits and medical and rehabilitation benefits.
After an individual has applied for and has started receiving accident benefits, the insurer will often request that the individual attend an insurer's examination in order to determine their ongoing entitlement to a particular benefit.
Section 44 of the Statutory Accident Benefits Schedule states that if the insurer would like an individual to attend an insurer's examination, they must provide a notice at least five business days prior to the examination that sets out the following:
- The medical and any other reasons for the examination
- Whether the individual is required to attend
- The name of the person conducting the examination, along with their specialization
- The date, time and location of the examination
Determining whether the insurer has provided appropriate rationale for conducting the examination can be complicated. For example, simply mentioning the existence of a specific medical record is not sufficient to justify an assessment. Stating that the purpose of the assessment is to determine whether an individual's impairment is predominantly a minor injury might also not be sufficient.
The Schedule also provides that the insurer cannot ask individuals to attend insurer examinations more often than is "reasonably necessary". Factors that are considered in determining whether an examination is reasonably necessary include the timing of the request, the number and nature of previous insurer examinations, and whether the insurer has been provided with new information to suggest a change in the individual's condition or a new diagnosis.
The examination itself typically involves an in-person assessment with a healthcare professional. Depending on the nature of the assessment, the assessor may conduct a physical examination of the individual to determine whether they have any physical limitations. Other examinations might be limited to having the individual complete questionnaires. The assessments usually also involve an interview, where the assessor asks the individual questions about a number of topics, including the accident, their injuries, and their pre-accident health.
If your accident benefits insurer has asked you to attend an insurer's examination, a lawyer can help you understand why you are being asked to attend, as well as whether the request is reasonable.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.