Motor Vehicle Accidents
The Ontario Automobile Insurance Anti-Fraud Task Force Steering Committee has released its Final Report to the Minister of Finance.
The Committee makes several recommendations, including:
- The formation of an Anti-Fraud Awareness Implementation Group;
- Require insurers to disclose publicly how they choose and assess the performance of businesses and professionals they recommend to consumers or refer them to see, such as independent medical examiners;
- Require insurers to ensure their public information on how consumers may register a complaint is simple to understand and easy to locate;
- The government should reduce uncertainty and delay for those who have legitimate auto insurance claims;
- Implement a province-wide licensing scheme for the towing industry;
- Collect information about towing expenses to facilitate analysis of relationships between tow operators, collision repair facilities and health care clinics;
- Take steps to reduce unreasonable storage costs for vehicles damaged in a collision;
- Permit insurers to collect a cancellation fee from claimants who fail to attend a medical examination at the agreed time, without reasonable notice or explanation;
- Insurers should move aggressively to establish an organization that would pool and analyse claims data to identify potential cases of organized or premeditated fraud;
- Require the licensing of health clinics that treat and assess auto insurance claimants and empower FSCO to regulate their business practices, as well as oversee and audit the business and billing practices;
- Additional powers for FSCO to conduct fraud investigation and enforcement;
- Require claimants to confirm attendance at treatment facilities and receipt of goods and services billed to insurers;
- Require insurers to itemize the list of invoices they have received when they provide a benefit statement to a claimant every two months;
- Allow insurers to suspend income replacement benefits when there is compelling evidence the claimant has submitted a fraudulent claim in conjunction with an effective, timely and robust dispute resolution system; and
- Health regulatory colleges should enhance their understanding of the consequences associated with fraud and ensure that complaints are investigated and lead to disciplinary action where appropriate, as well as develop professional standards, guidelines and best practices to improve the quality of independent medical assessments of auto insurance claimants conducted by their members.
The entire report can be read by clicking here.
The Financial Services Commission of Ontario (FSCO) has released a new Assessment and Treatment Plan (OCF-18) form, a new Treatment Confirmation Form (OCF-23) and a new Auto Insurance Standard Invoice (OCF-21) for use effective November 1, 2012. Older versions of these forms will not be allowed as of that date.
You can download these new forms directly from our website by clicking on the links below:
A major decision with respect to the definition of “catastrophic” under the Statutory Accident Benefits Schedule was released by the Ontario Court of Appeal today.
It its decision, Pastore v. Aviva Canada [2012 ONCA 642], the Court has supported the findings of the Director’s Delegate at the Financial Services of Ontario, who decided that only one functional impairment due to a mental or behavioural disorder at the marked level is necessary to declare a person’s injuries as catastrophic. Furthermore, the decision supports that a marked psychological impairment caused by physical pain is valid for the purpose of determining a catastrophic impairment.
The decision can be read in its entirety by clicking here. Pastore Appeal
An arbitrator at the Financial Services Commission of Ontario (FSCO) has ruled that a person providing attendant care for an insured is not required to provide their academic records to the accident benefits insurer.
In Mary Anthonipillai and Security National Insurance Co./Monnex Insurance Mgmt. Inc. [FSCO A11-001168] the daughter of the claimant, Mary Athonipillai, was providing housekeeping and attendant care services for her mother while she was attending university. The insurer, Security National, requested a copy of the daughter’s academic records because it took the position that the amount of attendant care and housekeeping services provided seemed excessive if the daughter was attending school at the same time. It was unknown if she was a part-time or full-time student and the daughter ignored all requests from the insurer for this information. Security National believed that the lack of this information was prohibitive to any meaningful settlement discussions.
Arbitrator Jessica Kowalski stated,
I am not persuaded that the records are so relevant that their non-disclosure now would prejudice a just and fair hearing so that I should therefore set aside privacy concerns around documents that contain information personal to a third party but none about a party to this proceeding.
Nor am I persuaded that the academic schedule is as probative as Security National asserts. That schedule will not disclose how often, or even whether, Ms. George attended her classes.
For these reasons, the motion is dismissed.
A recent decision by the Financial Services Commission of Ontario (FSCO) confirms that an insurer cannot necessarily deduct attendant care benefits from times when a claimant is receiving medical or rehabilitation treatment.
In Ms. T.N. and The Personal Insurance Company of Canada [FSCO A06-000399] the Arbitrator Suesan Alves stated the following:
The Personal submitted that it should be permitted to deduct chiropractic, osteopathic, massage therapy and six hours of rehab social worker and one hour of social worker treatment from any award of attendant care benefits. I disagree.
The benefits that The Personal seeks permission to deduct are provided under section 14 and 15 of the Schedule. Attendant care benefits are provided under section 16 of the Schedule. Each section of the Schedule provides for different and distinct services.
The focus of the Schedule is to provide services which meet the needs of an insured person. Under the statutory scheme, an insured person is entitled to medical, rehabilitation and attendant care benefits based on the criteria of need or necessity and reasonableness. In this context, it seems an odd concept to contemplate deducting one equally necessary benefit from another. If that were permissible, then an insured person would be required to choose, for example, between receiving assistance with a bath from his or her attendant, or receiving a physiotherapy treatment.
I am not persuaded that double payment would result from the provision of both attendant care and medical and rehabilitation benefits. Although the Form 1s filed by the Applicant contemplate the provision of attendant care 24 hours per day, 7 days per week, the rate prescribed for care in the completed forms is $7.00 per hour. Effective March 31, 2010, the minimum wage in Ontario became $10.25 per hour.
In a letter dated October 9, 2008, the claims handler informed counsel for the Applicant that the cost of the services of a certified support worker from a private agency which provides attendant care services in Ms. N’s area is $21.00 per hour. If Ms. N purchases attendant care services from that agency, she will be able to purchase approximately eight hours of attendant care per day.
I do not see attendant care and treatment as being mutually exclusive. Had the Legislature intended to permit the deduction of medical and rehabilitation benefits from attendant care benefits it could easily have done so expressly. For these reasons, I am not persuaded that the Legislature intended that other benefits would be deducted from attendant care. For these reasons, I reject The Personal’s submission that I permit the deduction of chiropractic, osteopathic, massage therapy and six hours of rehab social worker and one hour of social worker from any award of attendant care benefits.
The Ontario Auto Insurance Anti-Fraud Task Force Steering committee is seeking public input on a number of potential recommendations prior to their final report in the fall of 2012.
These recommendations include:
- Regulation of health clinics
- Regulation of the towing industry
- Enhanced authority for FSCO to regulate the business practices of health care treatment and assessment facilities
- Tightened controls on the delivery of Accident Benefits, including requiring the patient’s signature on invoices before they are submitted, a second Examination under Oath, and billing claimants $500 if the claimant fails to attend an insurer’s examination. Also being considered is requiring insurers to provide itemized statements to claimants every 60 days
- Amending the consent provisions of the auto insurance applications to provide greater certainty about the ability to share information for the purpose of detecting and preventing fraud.
- Provide insurers with broader civil immunity to protect them from lawsuits for reporting suspicious behaviour to regulators and the police
- A website devoted to informing those injured in motor vehicle accidents about accident benefits and how to detect and report suspicious or inappropriate behaviour
- Mandatory disclosure by insurance companies to the public about how they select and supervise their preferred providers of services – including independent medical examinations
- For FSCO to hire appropriate staff and resources to carry-out these recommendations
The entire update can be read by clicking here.
A recent Ontario Court of Appeal ruling confirmed that it is possible for someone injured in a motor vehicle accident to work but still be entitled to a Non-Earner Benefit.
In the decision, Galdamez v. Allstate Insurance Company of Canada [2012 ONCA 508], Hayfa Galdamez returned to work shortly after her accident. Because of this, Allstate took the position that she was not entitled to income replacement benefits. However, even though she was able to work, her medical professionals were of the opinion that she met the test for a non-earner benefit; namely, that she suffered a complete inability to carry on a normal life.
It has been well established in case law that entitlement to a non-earner benefit goes beyond the ability to simply go through the motions of everyday life.
The Court stated the following:
 Although I consider it unlikely that persons who can work at their pre-accident jobs following an accident will often meet the disability standard for non-earner benefits, I do not rule out such a possibility.
 For example, in jobs where mobility is not a requirement (e.g. department store greeter, telemarketer, etc.) and the job was not of great importance in the claimant’s pre-accident life, it may be possible for a claimant who returns to his or her pre-accident employment following an accident to satisfy the test for non-earner benefits.
This decision can be read in its entirety by clicking here.
Dr. Pierre Côté has been awarded the consulting contract by the Financial Services Commission of Ontario (FSCO) to develop the Minor Injury Protocol. Dr. Côté is Associate Professor, Dalla Lana School of Public Health, at the University of Toronto.
The Finanacial Services Commission of Ontario (FSCO) has released the 2012 Professional Fee Guidelines.
According to the FSCO website, the revised guideline increases the maximum hourly rates by 2.9 per cent. This increase is based on the 2011 Consumer Price Index (CPI) and applies to services rendered on or after July 14, 2012.
You can read a copy of these guidelines by clicking on the line below.
A recent decision delivered by Justice Ray in Henry v. Gore Mutual Insurance Company, 2012 ONSC 3687, found that an automobile insurer must pay an insured the full amount of attendant care benefits as set out in the Form 1 and is not entitled to take a proportional approach to the payment of this benefit. Gore Mutual Insurance argued that its liability for attendant care benefits was limited to the number of hours that the attendant care provider lost from work. Justice Ray did not agree with this approach and stated that a plain reading of the relevant section must be followed. In the decision, Justice Ray stated the following:
A plain reading of the section provides that if a family member stays home from work, loses income in order to provide all reasonable and necessary attendant care to the insured – and the insured is obligated to pay, promises to pay or does pay the family member, then the definition in section 19(1) has been met. All reasonable and necessary attendant care expenses must then be paid to the insured as described in the Form 1.
The decision can be read in its entirety here: Henry v Gore Mutual Insurance Company, 2012 ONSC 3687