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Posts Tagged ‘accident benefits’

A Story of One Man’s Struggles with his Accident Benefits Insurer

There is a very interesting story on one man’s struggle to get his accident benefits in a timely manner after a horrific crash with very serious injuries.

Unfortunately, his story is all too common for many individuals who are injured in motor vehicle accidents.

To read this article, click here.

FSCO Revises HCAI Guidelines

The Financial Services Commission of Ontario (FSCO) has released a bulletin which will revise the guidelines for the Health Claims for Automobile Insurance (HCAI) system, effective December 1, 2011.

These changes include:

  • Health care professionals will only be able to invoice the insurer at the completion of their treatment plan, or once every 30 days if the treatment extends beyond a month;
  • A statement that repeated and/or deliberate submission of duplicate invoices and invoices for non-approved goods and services may be considered by HCAI to constitute a contravention of HCAI’s terms and conditions and result in suspension or revocation of the health care provider’s access to HCAI;
  • A section on recordkeeping has been added to the new Guideline as an extension of Property and Casualty Auto Bulletin A-02/11, Insurer Rights and Responsibilities to Challenge Questionable or Abusive Claims; and
  • Changes have been made to the Appendix 3 Validation Rules in order to provide more clarity for the user.

The bulletin also notes that, effective July 1, 2012, FSCO will issue an amended OCF-21 form that will provide that the “Plan Number” of the OCF-18 or OCF-23 to which the OCF-21
refers is a mandatory field.  This is the unique number generated by the HCAI system when the OCF-18 or OCF-23 to which the OCF-21 refers is submitted, and will enable insurers to properly reconcile invoices.

To read the FSCO Bulletin in full, click here.

FSCO Revises Minor Injury Guidelines

The Financial Services Commission of Ontario (FSCO) has released a revised Minor Injury Guideline (MIG) that becomes effective on November 1, 2011.

The revised MIG provides direction for billing practices when a claimant changes health practitioners within the MIG, and direction on the integration of extended health care benefits with the MIG.
Included in the revisions is direction on payments to more than one health practitioner when a claimant changes practitioners within the MIG.  Now, where a claimant changes health practitioners, the first health practitioner may only bill 25% of the amount otherwise payable for a Block for each week or part week in which that health practitioner provided treatment under the Block.
FSCO has also clarified that the SABS rules regarding extended health care (collateral) benefit carriers as first payers have not changed.  Benefits covered by an extended health care plan must be exhausted first.  Amounts covered by other sources do not reduce the overall $3,500 cap for medical and rehabilitation benefits.

The actual revisions to the MIG can be accessed by clicking here.

Personal Insurance Hit With $28,000.00 Special Award

In a recent arbitration decision through the Financial Services Commission of Ontario (FSCO), The Personal Insurance Company of Canada was subjected to a $28,000.00 special award for unreasonably withholding accident benefits from their insured.

In Hoang and Personal, Arbitrator Denise Ashby found that The Personal unreasonably withheld payment for lost educational expenses and the costs of rehabilitation support worker services for Christopher Hoang, an 11 year-old boy who suffered a catastrophic brain injury from a motor vehicle accident.

Arbitrator Ashby noted that The Personal failed to reasonably assess the medical information available and acted unreasonably in denying his claim.  She noted that The Personal’s reliance on insurer’s examinations, “…in the face of the overwhelmingly consistent opinions and reasoning of the [treatment] Team and the other professionals who followed Christopher, amounts to an unreasonable disregard of the available information relating to the two rehabilitation benefits.”

Health Provider Survey Reveals Concerning Trends

An interesting article has been posted by the Alliance of Community Medical and Rehabilitation Providers on The Health Professional website.

Based on a survey of health professionals across Ontario it noted the following trends with insurer’s response to applications for medical and rehabilitation benefits:

  • A significant increase in the number of accident victims who are running out of benefits before they are fully recovered
  • Health care service denials have escalated
  • Victims are waiting longer to receive treatment and services
  • Many accident victims are now NOT being assessed
  • Victims are waiting longer to receive treatment and services

The article quotes Dr. Donna Ouchterlony, medical director of the Brain Injury Clinic at St. Michael’s Hospital, as stating that, “Since September, we are seeing more and more patients with serious injuries whose insurers are outright denying treatment, and when funding is approved, it is no longer nearly enough.”

The Alliance makes a number of recommendations:

  • Re-instate the benefits that were in place prior to last September
  • Allow the cap on assessments to be exceeded in certain circumstances
  • Withdraw the right of insurance adjusters to deny medical claims without an independent medical opinion
  • Freeze premiums
  • Require more openness and transparency, with insurers having to release financial and operations data for their auto insurance lines

The full version of the article can be found by clicking here.

Are you in the MIG? Maybe not.

Claims Canada Magazine is reporting that more than 50 percent of all claims in Ontario are currently falling under the Minor Injury Group (MIG). The article acknowledges that insurance companies are “holding their breath” to see how arbitration and judicial decisions will interpret the new regulations as to what is and is not considered a “minor injury”.

Interestingly, the question still remains open as to whether or not individuals who were injured after September 1, 2010 but prior to their policy renewal date can be placed within the MIG category and, more importantly, the $3,500.00 limit for medical and rehabilitation benefits, as this is based on a bulletin from the Financial Services Commission of Ontario (FSCO). A bulletin is not law.

Economical Insurance To Pay Special Award

A recent Arbitration ruling by the Financial Services Commission of Ontario (FSCO) has ordered Economical Insurance to pay a $6,000.00 special award for unreasonably withholding attendant care benefits from one of their policyholders.  In the matter of Mr. S. and Economical Mutual Insurance Company, the Arbitrator identified that the insurer relied on its own surveillance and not even their own medical experts when determining the amount of the attendant care benefit.

FSCO Mediation Wait-List Times Decreasing

Smitiuch Injury Law has received confirmation from the Financial Services Commission on Ontario (FSCO) that steps are being taken to decrease the wait time for mediations from the current nine months.  Mediators at FSCO are now conducting three mediations per day instead of two.  This should help alleviate the backlog for disputes against insurers for denied accident benefits and, ultimately, will mean that clients will be able to have quicker resolution of their accident benefits claim issues.

A golf cart driving on a highway without insurance is a “motor vehicle”

A golf cart driving on a highway without insurance is still a ‘motor vehicle’ for the purposes of accident benefits. Arbitrator Kominar – “…certain classes of vehicles, including golf carts, when they are operating on property other than highways, it does not follow that ‘if’ those conveyances choose to venture out, illegally, onto highways that they are exempt from insurance requirements…”

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