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Archive for December 2013

Health Care Clinics to be Regulated by Ontario Government

The Government of Ontario has filed regulations governing health care clinics and assessment centres who provide services paid for by automobile insurers.

The following was reported on Willie Handler’s Blog this morning.  Mr. Handler formerly worked in auto insurance regulatory policy for the Ontario government.

The Ontario Government filed new regulations as part of the process to eventually license health care clinics and assessment centres operating in the auto insurance sector.  The regulations cover a public registry of licenced facilities (Regulation 350/13), licensing of providers (Regulation 348/13) and requirements of the principle representative of each licensed facility (Regulation 349/13).  The report recommending a licensing system was made by the Automobile Insurance Anti-Fraud Task Force in 2012.

Public Registry

The public register of licensed and former licensed service provider’s licence to be maintained must contain the following information about each licensee and former licensee:

1. The name in which the service.
2. The licence number.
3. The licensee’s mailing address in Ontario.
4. The date on which the licence was issued.
5. Whether the licence is in good standing or is suspended.
6. Any conditions that apply to the licence.
7. Any periods of time during which the licence was suspended.
8. Any periods of time during which the licence was revoked.
9. The name of the licensee’s principal representative.
10. The address of every facility, branch or location in Ontario of the licensee.

Eligibility criteria for facilities

A service provider’s licence may be issued to an applicant if all of the following requirements relating to the applicant’s business systems and practices and the management of its operations are satisfied:

1. The applicant has a mailing address in Ontario that is not a post office box.
2. The applicant has an email address.
3. The application includes the particulars of the individual to be designated as the service provider’s principal representative.
4. The principal representative has provided an attestation on the applicant’s behalf relating to the applicant and the application and relating to the applicant’s compliance with the Act.
5. The application includes the particulars of each facility, branch or location in Ontario that the applicant operates or intends to operate.
6. The applicant must agree to bill insurance companies through HCAI.

Unsuitable Applicants

In determining whether an applicant is not suitable to hold a service provider’s licence, the Superintendent is required to have regard to the following circumstances:

1. Based on past conduct of the applicant, there are reasonable grounds for the belief that the applicant will not carry out in accordance with the law or with integrity and honesty the completion or submission to an insurer, reports, forms, plans, invoices or other documentation or information authorized under the SABS.
2. Whether, having regard to the past conduct of any of the following persons, there are reasonable grounds for the belief that the applicant’s business systems and practices and the management of its operations will not be carried on in accordance with the law or with integrity and honesty:

  • The applicant.
  • If the applicant is a corporation, a director, officer or shareholder of the corporation.
  • If the applicant is a partnership, a partner of the partnership.
  • If the applicant is a sole proprietorship, the sole proprietor.
  • The person to be designated as the applicant’s principal representative.
  • An employee, agent or contractor of the applicant.

3. Based on past conduct, there are reasonable grounds for the belief that the applicant’s business systems and practices and the management of its operations will not be carried on in accordance with the law or with integrity and honesty.
4. Whether anyone associated with the business is engaged in a business or undertaking that would jeopardize the applicant’s integrity and honesty in relation to the applicant’s business.
5. Whether anyone associated with the business has made a false statement or has provided false or deceptive information to the Superintendent, with respect to the application for a licence, or in response to a request for information by the Superintendent.

Eligibility criteria for principal representatives

An individual who satisfies the following criteria is eligible to be designated by a licensed service provider as its principal representative:

1. The individual has the following status in relation to the licensee:

  • If the licensee is a corporation, he or she is a director or officer of the corporation.
  • If the licensee is a partnership, other than a limited partnership, he or she is a partner.
  • If the licensee is a limited partnership, he or she is a general partner or a director or officer of a corporation that is a general partner.
  • If the licensee is a sole proprietorship, he or she is the sole proprietor.
  • If the licensee is not a corporation, a partnership or a sole proprietorship, he or she is responsible for the day-to-day control and management of the licensee.

2. The individual has the authority to make decisions on behalf of the licensee with respect to matters related to the licence and matters related to the licensee’s compliance with the Act and to communicate with the Superintendent about those matters.
3. The individual has the authority to exercise the powers and perform the duties described above.

Powers and duties of principal representatives

1. Take reasonable steps to ensure that the licensee complies with the Act.
2. Take reasonable steps to ensure that the licensee’s business systems and practices and the management of the licensee’s operations are carried on in accordance with the law and with integrity and honesty.
3. Ensure that the licensee takes reasonable steps to deal with any contravention of the Act.
4. Make recommendations to the licensee regarding changes in its business systems and practices and the management of its operations, as necessary, to ensure that these standards are achieved.
5. Take reasonable steps to ensure that a system of supervision is in place to ensure that these standards are achieved.
6. Provide such attestations on the licensee’s behalf relating to the licensee and relating to its compliance with the Act, as may be required by the Superintendent and within the time required by the Superintendent.

Scarlett and Belair Appeal Allowed – Remitted to Another Hearing

The Financial Services Commission of Ontario has allowed the appeal of a previous arbitration decision with respect to the Minor Injuries Guidelines (MIG).

In the appeal decision Scarlett and Belair Insurance [FSCO P13-00014] Director’s Delegate David Evans allowed the appeal of the earlier decision by Arbitrator Wilson.  Our original blog post on this decision can be referenced by clicking here.

Director’s Delegate Evans has ordered that all issues be subject to a full hearing before another arbitrator.

This appeal decision provides a few glimpses of what is likely to come from a new arbitration hearing with respect to the Minor Injury Guidelines:

  1. The dominant test of whether a person falls into the MIG is if the injury was predominantly a minor injury;
  2. The burden of proof always rests on the insured, not the insurer, of proving that he or she fits within the scope of coverage;
  3. “Compelling evidence” is more than “credible evidence”; and
  4. The MIG is binding and is not only advisory.

The Director’s Delegate also noted that the arbitrator’s decision breached procedural fairness by raising cases and statutory provisions of his own accord after the arbitration hearing without providing notice to the parties or an opportunity to respond.

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