My insurance company’s medical examination denied me surgery.

Question:
I was in a motor vehicle accident about 2 years ago in July. My insurance company’s medical examination denied me surgery for my mouth (an air bagged deployed in my face). I now have extensive problems regarding such.

Through investigation, my dentist found out that the man who did the exam for the insurance company wasn’t even a qualified Dentist, let alone an Orthodontist. What are the procedures to overturn the decision and prove them wrong? Or, Should I just pay out of pocket to get it done?

They are refusing to pay prescriptive meds for injuries for over $5000. I have now experienced two hip surgeries, am unable to drive and they have denied treatment plans for my physiotherapy and massage therapy, despite reports from my general practitioner. I’m also still in need of assistance in doing everyday tasks like bathing.

Please let me know what I should do as I’m at my wits end. Thanks in advance, Rhona!


Answer:
If you don’t have a lawyer, you should call one immediately. You have a 2 year limitation period to sue for your accident. That limitation period will expire next month. If you haven’t started a claim before the second anniversary of your accident you may be prevented from ever suing.

About your questions: It appears that your dentist put in a treatment plan for surgery and treatment for your mouth. The insurance company denied the treatment and sent you to their own specialist who agreed with the insurance company. The next step in disputing the position of the insurance company is to have your dentist do a rebuttal report. In the rebuttal report your doctor can discuss the qualifications of the insurance company doctor. If the rebuttal report doesn’t change the adjusters mind then the next step is to apply for mediation at the Financial Services Commission of Ontario.

You can apply for mediation on all of the denied treatment plans. After mediation, if the problems are not resolved, you either apply for arbitration or sue.

I would strongly urge you to call a lawyer in your area as soon as possible.