Toronto Sun – Deny and delay on Hamilton man’s insurance claim

By Michele Mandel ,Toronto Sun
First posted: Thursday, November 17, 2011

HAMILTON – William Huang flatlined on the operating table at St. Michael’s Hospital.

It was just ten days before Christmas last year and the 52-year-old millwright was delivering gifts in Etobicoke when a dump truck suddenly ploughed directly into the driver’s side of his van. It took emergency responders an hour to cut him out of his crushed vehicle and when they got him to the trauma centre, his condition was so grave that the father of two was given last rites.

Almost a year later, the memory still reduces his 18-year-old son to tears. “I thought I was going to lose him,” Richard says.

After he was resuscitated, Huang’s family was told he had only a 50-50 chance of making it through the night. The force of impact had shifted all the organs of his body to the right, fractured his spine, his hip, his leg and left him with serious internal bleeding. He would need 20 blood transfusions and numerous operations, but after six weeks in St. Mike’s ICU and another four and a half months in Hamilton General Hospital, Huang was finally discharged in May.

But his tough battle to survive has been nothing compared to the one he’s been cruelly forced to wage with his insurance company.

Huang will never be able to breathe through his mouth or nose. He has a permanent tracheostomy tube and can speak only with a microphone to his voicebox or through a computer that reads out what he’s typed. He needs 24-hour care because if the tube clogs with mucous, he will die.

He is scarecrow thin and terribly weak. He’s in constant pain and sleeps in the den downstairs because it’s too difficult to manage the stairs up to his bedroom. He’ll never be able to return to the job he loved and he’s had to close down his business. He’s on 13 medications, including one that costs $735 a prescription.

He is a proud man. “I was the main breadwinner and I feel like I let my family down,” Huang says slowly.

Life, he says, is as different now as “night and day.” How unfair that with everything he must endure, he also has to withstand the slow torture of dealing with adjusters from Intact Insurance, who seem determined to place roadblocks at every turn: holding up cheques, refusing to recognize his catastrophic injuries, claiming forms have been lost in the mail — all while the family runs through their savings.

“It just makes me angry and frustrated,” he says. “They want their money but when roles are reversed, they’ll do anything not to pay.”

Just getting his income replacement benefit was a struggle. The maximum is $400 a week, but as he lay in intensive care hooked up to machines, they would give only $150 on the chance he could soon work. Intact then failed to pay anything at all for two months over the summer. With no apology, their adjuster blamed it on “system failure.”

“It was our mistake and for that we are deeply sorry,” Intact spokesman Sandra Nunes tells the Toronto Sun. “We took corrective measures to resolve the issue with catch-up payments and accompanying interest.”

He almost couldn’t be discharged, he says, because Intact hadn’t paid for the breathing equipment he needed at home. And now they’re stalling again.

If his insurer determines the accident left Huang with a “catastrophic impairment”, his benefits go from $100,000 to $1 million to cover his very expensive rehabilitation, prescription and medical costs. His trauma surgeon at St. Mike’s filled out the form last May. In September, Intact said their own doctor says Huang’s condition hasn’t “stabilized” so they won’t assess him yet.

Deny and delay seem to be their operative words.

Meanwhile, much of the worry falls on his wife Davanh and their son, who are in constant battle with Intact. “It scares me to death,” Davanh says, breaking down. “How am I going to pay bills and what about my son? How are we going to keep going without help, without money?

“When you buy insurance, you depend on that, thinking insurance is going to help you out. Then you have to fight for everything, every step of the way.”

Toronto Sun – Adjusters forgetting ethics

I’d suggest insurance adjusters invest in new fax machines and get more organized.

By Alan Shanoff ,Toronto Sun
First posted: Saturday, November 05, 2011

“The Adjuster shall so act as to promote public confidence in insurance companies through fair and conscientious dealing, and shall refrain from any fraud, deceit, misrepresentation, dishonest non-disclosure, undue influence or other mischievous practice.” — The Code of Ethics of the Ontario Insurance Adjusters Association.

Do you think insurance adjusters hired by the City of Toronto to handle property damage claims submitted by residents read their own code of ethics?

You’d be hard pressed to believe so after reading the city Ombudsman’s report describing what can only be seen as a systemic abuse of claimants.

Claims are routinely denied, with adjusters advising claimants investigations have been completed, when no investigation has been launched.

Files are closed without any communication, while residents wait for answers.

Do you think car insurance adjusters are better?

Consider this recent Ontario Superior Court of Justice decision in a lawsuit against Echelon General Insurance.

Edith Whorpole of Pefferlaw died in a horrible accident on Oct. 3, 2007.

Her brother, acting for the estate, submitted a claim for the loss of the vehicle.

He placed the value at $5,751 while the adjuster pegged it at $4,474.

The brother’s evidence was the adjuster said the loss would be paid, it was just a matter of “paperwork” and there was “no need to sue”.

The brother submitted a Proof of Loss in May and September of 2008.

With no response to the first and the adjuster denying receipt of the second, a third Proof of Loss was submitted Oct. 3, 2008.

But on Oct. 9 the adjuster sent a letter denying the claim, stating the one-year period to sue had expired.

If you think that bit of “gotcha” was bad, the adjuster, without notice, arranged for the smashed vehicle — still containing his sister’s blood — to be dumped on the brother’s driveway, blocking the entrance to the house. I can only imagine the distress that would have caused.

This was too much to take and the brother sued in October 2009, not just for the value of the car, but for punitive damages for breach of the duty of good faith and fair dealing.

Instead of a modest claim, now the insurance company faced a much larger suit along with attendant legal fees.

The insurer’s lawyer attacked the lawsuit, claiming it was brought too late, the one-year limitation period having expired.

Justice T. A. Heeney would have none of that argument. He dismissed the motion earlier this year, ruling the action should proceed to a trial.

Now consider another recent case where Ontario Superior Court Justice Wendy L. MacPherson tossed out a low ball settlement between an adjuster and an injured motorcyclist.

This on the basis an ING adjuster abused his position of power to enter into an unconscionable settlement.

These are but two cases. The Toronto Ombudsman’s review covered 12,449 claims, so it’s pretty clear adjusters need some schooling on their own code of ethics.

At the same time, I’d suggest adjusters invest in new fax machines and get more organized.

It’s amazing how often faxes appear to get lost and documents misplaced at adjusters’ offices, thereby delaying claims.

It’s also amazing how frequently adjusters refuse benefits or payments on the basis the item requested is “not considered reasonable and necessary.”

Of course the reason the item isn’t considered reasonable and necessary is rarely disclosed, so perhaps adjusters also need a remedial course in communication.

After all, as the Toronto Ombudsman informed us, city adjusters appear reluctant to advise claimants when their files have been closed, thereby leaving claimants twisting.

Look, we know there are good adjusters and not all are of the “deny and delay” school of thought, but clearly this is one industry in need of a course in remedial ethics.

Toronto Sun – ?Generous? accident benefits?

Contrary to insurance industry claims, Ontario has lowest minor injury benefits in Canada.

Click here to read the rest of the story.