Disputing a $200 claim? How far auto insurers must go to prove fraud

Thanks to the meticulous analysis and collection of evidence provided by a professional engineer, Sonnet Insurance has recovered a $200 auto accident benefits payment obtained by a driver who submitted an inaccurate accident report to her insurer.

However, the insurer did not succeed in its bid to recover $1,000 in legal costs incurred when the claimant refused permission to combine the matter with four other similar files submitted to the insurer. The move forced Sonnet to pay additional legal fees to deal with each matter individually, the carrier argued.

If anything, the outcome of the LAT hearing shows the lengths to which insurance carriers must go to recover auto accident benefits claims that the tribunal deems to be fraudulent.

Ontario’s Licence Appeal Tribunal (LAT) noted the driver, Fadumo Aden, did not make a submission to the written hearing. Aden applied to her auto insurer, Sonnet, for accident benefits after she said her car was damaged in a vehicle accident on Highway 427 in Toronto.

In her insurance claim, Aden told Sonnet she was rear-ended by an unknown driver. She maintained she was hit again on her door side by the same unknown driver after her vehicle spun out of control following the initial impact. The other vehicle fled the scene of the accident.

Sonnet’s expert witness at the written hearing, a professional engineer, disputed this claim. He said the damage was more consistent with the car being hit by a square metal tube, as well as the damaged car clipping a stationary car door.

Ultimately, the LAT sided with the insurer’s expert witness in the absence of any claimant submissions to the contrary. The car was not damaged in an accident, LAT’s adjudicator ruled.

“I find the [driver’s] reported version of events is not supported by evidence presented to me,” Ontario LAT Adjudicator Tanjoyt Deol wrote in her decision, released last Thursday. “The discrepancies between her evidence and [engineer Harrison] Griffiths’ opinion of how the collision occurred were significant and have not been adequately explained.

“On a balance of probabilities, I find [Sonnet] has proven that the [driver] misrepresented critical facts regarding the collision. This misrepresentation was material, as it allowed the [driver] to receive accident benefits from [Sonnet].

“The misrepresentation was also willful, as the [driver] described an inaccurate version of the collision to [Sonnet] during the EUO [examination under oath].”

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Aden told Sonnet in March 2021 she was driving her 2004 Nissan Truck Murano in the middle lane of Highway 427 to pick up food from a restaurant.

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In her claim for benefits, she said another car came into her lane, struck her vehicle on the driver’s side, which caused the vehicle to spin.

At her EUO, Aden “largely described the accident in the same fashion, but provided further details that her Nissan had been struck at the rear before spinning and being struck on the driver’s side,” Deol wrote.

Sonnet disagreed and hired a professional engineer to testify as an expert witness. He testified the damage was not caused by a vehicle accident.

“Griffiths…concluded that the rear end damage to the Nissan was inconsistent with vehicle-to-vehicle contact and instead could be attributed to multiple separate impacts from the end of a square metal tubing, and that there was no mechanism to induce the loss of control or spin reported,” Deol writes.

“Furthermore, the damage to the driver’s door was consistent with a low-speed sideswipe engagement with either the edge of an open front door or a vehicle that may have been stationary.

“With respect to the right front corner damage, Mr. Griffiths concluded that the damage was inconsistent with the reported vehicle motions, and it was more characteristic of an impact with a short, rigid, abrasive object.”

To prove his point, Griffiths inspected the Nissan, Deol writes. Then he “purchased metal tubing and conducted impact testing on a test vehicle that was of a similar model and year to the Nissan, took photographs of both the damage to the Nissan and test vehicle, reviewed a documented real-world collision between a 2003 Nissan Murano that was rear-ended by a 2005 Lincoln Continental, and conducted door ding contact testing and contact with an open front door edge testing on the test vehicle,” Deol writes.

Since Aden did not attend the hearing, she did not challenge the testimony and evidence provided by Harrison, writes Deol. The LAT adjudicator went on to prefer the evidence of the engineer.

Deol ordered Aden to pay back the initial $200 accident benefit payment she received from Sonnet as a result of her claim.

But she said the insurer failed to establish Aden was uncooperative when it came to obtaining her consent to combine the related claims matters into one proceeding.

“I find that [Sonnet] has not established costs are warranted under these circumstances,” Deol found. “While it argues that it was impossible to obtain consent from [Aden] with respect to its motion because she has been evasive, it has not referred me to any evidence to support that it took any steps to obtain consent prior to the case conference.”

David Gambrill

David has twice served as Canadian Underwriter’s senior editor, both from 2005 to 2012, and again from 2017 to the present.