Insurance Questions Answered: A Claim Adjuster's Perspective

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Roger,

If the profits are so good up here in Ontario for motor vehicle insurance, you'd think those big American companies like Geico and Progressive would be up here in a heart beat. Remember Kingsway? They had super rates for motorcycles. Where are they now?

Don't get me wrong, I think rates are out of this world but, you're barking up the wrong tree my friend. The coverages you pay for are mandated by the provincial government. The rates are regulated by the provincial government.

As for taxes, that's a bit off topic but, I understand your position. But, you're not going to see any changes to the tax structure for education. There are folks that never have kids and pay taxes too.

Cheers.
 
GYMPY said:
At your age you are banking future tax dollars which you will need for further and possibly massive health care in the future when you get to my age of in the sixties
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I may very well be wrong, but my understanding is that the CPP/tax dollars from the current working generations go to support the current retired generation. You make it sound like your contributions from 20, 30, 40 years ago were set aside for when you need them when you retire. I think this is incorrect. You depend on tax dollars from younger generations; and when those younger generations get to your age, they will depend on even younger generations.

Our free education and health care systems work based on everybody footing the bill, regardless of what their needs are. You may argue that you're entitled to your old-age benefits because you "banked" them when you were younger. What about children? Do they get to "bank" to future school expenses when they're fetuses? Nope.

Think of it this way using your logic: when you're young, you "bank" for old-age; when you're old, you repay what you used when you were young.
 
Quick Questions, what kinda % increase do most insurance companies apply to premiums if the driver has a lapse in being licensed for over a year. No suspension, just never renewed?
 
Just one question:
Company will pay me the claim for my injuries if i had an accident on bike and had bike insurance.because i want to get a insurance policy for my bike?????
 
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Cody said:
Just one question:
Company will pay me the claim for my injuries if i had an accident on bike and had bike insurance.because i want to get a insurance policy for my bike?????
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Yes. That is what it is for.

Sent from my MB860 using Tapatalk 2
 
Just had a question because it is my first time for this. I received a letter from a SR. Claims adjuster that i am being sued for accident benefits for an amount greater than more coverage of $1,000,000. It advises me to contact a lawyer for the remainder of the amount, which is unknown. 2 years ago a different claims adjuster investigated the accident and told me not to worry they were fighting the claim and now this. I am fearful of financial ruin, is this typical reality for a family with single income? Any outlooks and advice/guidance would be helpful
 
Avi Singh said:
I'm curious. Do claims adjusters look at a claimant's past claims history? I was reading an autoplus report yesterday for someone, and over the last 4 years, they've had 4 not at fault losses with increasing AB payouts (totalling over $100k). The payouts on the vehicle were minimal (I think $405 was the highest). Is this something that claims adjusters look at?
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:eek:
 
All, great discussion...

How can we align the independents with the insurance preferred shops so that as a customer we know what we are getting, as opposed to getting screwed...

Also wanted to point out that "cheap Chinese parts" are no longer an exception, but more of the norm... Aircraft manufacturers and even the Canadian DOD recently recognized the risk from "approved" vendors using cheap rip-offs... agreed it comes at a cost, but what the heck can we the common Joe (and of course the Jacks, and Jills, Blls, Chucks and the ocassional Claudio, etc.) do about it? Squat, IMO?

So, to 2smokewilleh (very encouraging name btw), who incidentally started this thread, it would be really great if you can help us mere mortals identify how we can get good value for our money (repairs and insurance of course) so that we have a few cents left over for secondary items like FOOD!!!
-J
 
2) A person who lives in North York, Ontario driving a 2005 Honda Accord is rear-ended while stopped at a traffic light. There is $2000 worth of damage to the Honda. The person reports their claim then calls a personal injury lawyer that they heard an advertisement for on the radio. The personal injury lawyer advises them that to be able to sue, they need to prove that they are suffering from either permanent, serious or important disfigurement or impairment, and that they will make sure that they have all of their limitations assessed to help build their case. The lawyer then directs that person to visit a doctor who they know will give an inflated diagnosis, who assesses the person and states that they have Whiplash, Grade 3 injury, with cervicogenic headaches, depressed mood and irritability, Lumbar, thoracic and cervical spine sprain and strain, and dizziness, and completes a disability certificate stating that due to his injuries, he is not able to work or complete his housekeeping duties. A referral is made to have an in-home assessment completed to determine how much assistance that person needs to complete personal care and housekeeping tasks. That assessment is completed and because of pain due to the injury it is recommended that that person receive $1500/month in personal care assistance and $100/week in housekeeping assistance. That person does not return to work, and their income replacement benefit is calculated to be $400/week. They are then referred to a chiropractor who recommends that that person receive treatment 3 times a week for 15 weeks and massage therapy 3 times a week for 10 weeks. They are also referred to an assessment by a neurologist, to check into the headaches and a psychologist to assess their psychological issues. The neurological assessment could be covered under OHIP, but an appointment would take 4 months to get, however if the insurance company pays for it, it could be completed in a week. The neurological assessment is completed determining that that person is suffering from headaches that will resolve. The psychological assessment is completed and the person is diagnosed with mixed anxiety disorder with depressed mood, and 12 sessions of psycho-therapy are recommended to resolve the person’s psychological impairment. 6 months down the road, the treatment continues and no symptoms are resolving. The client then is sent back to that original doctor who declares that that person is suffering from “Chronic Pain” and a chronic pain assessment is recommended. Following completion of that assessment, the person is recommended for a treatment regimen completed by a variety of doctors/psychologists etc, and yet after 6 more months, the symptoms have not resolved. At the one year mark (the minimum amount that a person must wait before being able to settle an Accident Benefits Claim), the lawyer contacts the insurance adjuster and offers to settle the file for $50,000, including money for future treatment, income replacement, housekeeping and personal care assistance. After dealing and haggling with the adjuster, the file ends up settling for $15,000. The adjuster reluctantly agrees with this price as he is certain that the claim may end up costing more than that should he not settle.
The cost of this claim is as follows:
$20800.00 - 1 year of income replacement at $400/wk
$5200.00 - 1 year of housekeeping assistance at $100/wk
$18000.00 - 1 year of personal care assistance at $1500/month
$200.00 - for the initial Doctor appointment,
$63.72 - to complete the Disability Certificate
$263.72 - Chiropractor charges the $200 to complete the initial assessment for chiro and $63.72 to complete the forms.
$7500.00 - Cost of continued Chiropractic and Massage treatments over 6 month period
$1800.00 - Cost to complete the in-home assessment
$2500.00 - Cost to complete the neurological assessment
$2500.00 - Cost to complete the psychological assessment
$263.72 - Cost to complete the pre-psychological assessment screening interview and fill out the Application for Approval of Assessment for psych assessment.
$63.72 - Cost to fill out the Treatment Plan for Psych.
$2200.00 - Cost to complete the psychological treatment
$4500.00 - Cost of the Chronic Pain Assessment
$6563.72 - Cost of the Chronic Pain treatment plan/completion of form.
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Total cost of claim prior to settlement: $79618.60 + Settlement $15000 = $94,618.6
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Hi, Thanks for this. It provides a great explanation and breakdown. My question for you is I am in a similar situation the scenario in number 2. My accidents occurred in August and October 2009 so I fall under the old insurance umbrella. The first I was hit by a car while riding my bike. The driver was at fault and I did not break or fracture anything but got scraped up and was jolted hard when I hit the ground. I've been hit in my car in the past and got whiplash but was younger so didn't think it was a big deal and only claimed the car repairs and not any injury so I knew this time I wanted to ensure I got the proper treatment right away. I called a personal injury lawyer because I knew I would not be able to deal with the insurance company on my own. Long story short, I received treatment for about a year and half when the clinic I was going to told me they were not longer doing mva's so I would have to go elsewhere. My lawyer referred me to another clinic who treated me for a few weeks then told me my treatment plan had been denied so they could not continue to treat me. Since then (summer of 2011) I have not received treatment as the insurance company kept sending me letters saying that treatment was not "reasonable and necessary" I stopped getting treatment and am still in pain. Apparently, I should have healed in 6 months (I had just turned 29 when the 2nd accident happened) but I didn't. Even getting 3 treatments a week for over a year did not help and doctors said I had chronic pain syndrome. I also have all the Fibromyalgia symptoms and was told I have that as well. I found myself crying every day because I was in pain and unable to do the things I used to (I had always been a very fit, active person) and the emotional and physical pain combined has made life very difficult, I have had many, many moments where I felt suicide was the only way out (though I am convinced that I would never do it, sometimes I do scare myself when I am really, really low). My point is my life was radically changed in so many ways and I feel like so much has been taken from at such a young age. I feel like an old lady (I've also developed osteoarthritis in both of my large toes and ankle making just walking something I dread and avoid whenever possible. I feel like my life has been stolen. I am a completely different person than I was before the accidents. I am fearful and protect myself because I am afraid of getting hurt because I feel like a china doll that needs to be shielded. When I'm in a car I am always checking behind to make sure the person behind me will stop and not ram into me because they are avoiding a squirrel. I am left with conditions that I am told and have researched, that have no cure - Chronic Pain, Fibromyalgia, Osteoarthritis, not the mention the depression, anxiety and loss of the ability to do simple things like standing or walking down the street, without pain. And my benefits have been cut off and they want to settle for 35,000 (less 15,000 in treatment bills that were denied and the clinic continued to treat me without telling me, and 10,000 to my lawyer) leaving me with just under 15,000. To many that may seem like a good settlement but to me all I see is how little treatment that will buy (1 or 2 years if I'm lucky) so I worry that if these conditions don't improve I'm going to having to pay for physio ect for who know how long? Maybe the rest of my life? Not to mention the time I spend going to and getting the treatments. I would rather just have the 10 years of treatment that I am entitled to but if I don't take this settlement I will have to go to arbitration which could take a year or more and because chronic pain/fibromalgia/soft tissue damage (my back and neck are covered with painful knotty scar tissue that do not want release no matter how much treatment I get) but my lawyer does not think I will do well because their assessments determine that I am fine and they see no reason for my pain. They say it is all in my head (like many chronic pain and fibro suffers hear) and that the accidents were not severe. Yes, I did experience brain injury or paralysis or even break a bone, I think people underestimate the affect whiplash injuries have on the neck and back and how if they do not heal properly in the early stages can cause life long pain issues. I just feel so stuck. Oh, I should add that they never paid me the monthly housekeeping or any other benefits I was entitled to so I think they may have added that to the settlement offer. I feel like the only rational option is to accept the settlement because i probably will not pass all their medical tests that they will do again during arbitration. And If i lose, I will have to pay their legal fees and incur more disembursements. I also have a tort case but with the 2 accidents my deductible will be 60,000 so I am not sure what will happen there. My discovery is next month. I have lost nearly three years of my life to this pain and am worried that I will not have enough to pay for future treatments and will be stuck footing the bills because of someone else's negligence. It is just not right or fair that I am blown off because in their eyes I am not hurt enough. Maybe you can tell me if this is a fair settlement or not. My lawyers say its not the worst or the best they have seen so I'm not sure what to make of that. Did my lawyer fight hard enough or do they just want to be done with this so they can get paid. It is a large personal injury firm that advertises all over the place so I am sure that they work on volume. Anyway, sorry if this is too much to read. I apologize. I have just felt so stuck and scared to make the wrong decision and don't know where to find the answers. Any help you could offer would be greatly appreciated. THANK YOU SO, SO MUCH:)
Melanie
 
I was recently in a car accident in a parking lot. I backed out and was ready to change to drive to go forward when the other guy backed out without looking and hit my car. He was on the opposite of the aisle and one spot over to the right. He hit my car on the rear side of the back bumper left of the license plate. His car was scrapped on the left side of his rear quarter panel just behind the rear left door. From the pictures taken of the damaged areas, it is evident that his scraps were along the length of the car while my scraps were along the end of the bumper. The damage would appear to indicate he was moving while I was stationary. However, he says that almost all parking lot accidents are ruled 50/50. Unfortunately, there were no witnesses to verify that I was stopped and he was moving. Would the pictures of the damages be enough to verify that I was stopped and he was moving? Or is it true that parking lot accidents are ruled 50/50?
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