Posts Tagged ‘rehabilitation’
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.
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 Any periods of time during which the licence was revoked.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.
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.
Smitiuch Injury Law is pleased to host its annual seminar, entitled “Accident Benefits: Practical Issues for Health Care Professionals.” It will be held on Wednesday, September 25, 2013 at the Brantford Golf and Country Club.
The keynote topic at this year’s seminar will be on “Living With and Caring for an ABI Survivor – A Mother’s Perspective”. Bernie Perry, the mother of an acquired brain injury survivor, will identify the struggles and successes she has experienced in her daughter’s recovery and rehabilitation. Bernie will be accompanied by her case manager, Jody Abbot and Dr. Diana Velikonja, a clinical neuropsychologist at Storrie, Velikonja and Associates in Burlington.
The afternoon will also provide an update on the latest news and case law in Ontario Accident Benefits, followed by an open forum with an expert panel to answer participant’s questions. The expert panel will be composed of Ms. Heather Driver (Financial Services Commission), Tamara Forbes (Forbes Health Management), Anna-Marie Musson (Miller Thomson) and Chris Jackson (Smitiuch Injury Law).
The afternoon will begin with registration and lunch at 11:30 a.m. and will end with a cocktail reception and social at approximately 3:30 p.m.
This event is 100% complimentary.
If you wish to attend please RSVP no later than September 18, 2013 by calling 519-754-1558 or by email to [email protected].
A copy of the invitation can be accessed by clicking here.
The Financial Services Commission of Ontario (FSCO) has released an updated Professional Services Guideline for 2013.
According to the FSCO website, “The hourly rates are unchanged from the 2012 level. This is in line with the auto insurance rate reduction strategy outlined in the government’s 2013 Spring Budget.” It has also added a category for kinesiologists, who are now regulated health professionals in Ontario.
A copy of the 2013 Professional Services Guideline is available by clicking here.
The Financial Services Commission of Ontario (FSCO) has released the very first decision with respect to injuries that fall within the Minor Injury Guidelines (MIG).
In Lenworth Scarlett and Belair Insurance Company Inc. [FSCO A12-001079], Arbitrator John Wilson has provided clarification regarding what injuries subject an insured person to a maximum of $3,500.00 in medical and rehabilitation benefits.
While Mr. Scarlett suffered soft-tissue (whiplash) injuries in his motor vehicle accident, he was also diagnosed with Temporal Mandibular Joint Syndrome, as well as psychological issues. Despite the provision of documentation that supported injuries beyond those subject to the MIG, Belair maintained its position that he was subject to the MIG limits for accident benefits. As Arbitrator Wilson pointed out, “In essence, Mr. Scarlett’s attempts to claim certain benefits from Belair were being rebuffed because Belair took the position that he was within the MIG and either the benefits were not payable or they were in excess of what was required to be paid under that approach. This appeared to be a major stumbling block since, even when Mr. Scarlett provided further evidence of complicating features of his claim that in his mind took it outside of the MIG framework, he was met with the same response.”
Arbitrator Wilson outlined the critical elements of the MIG as follows:
- Persons who suffer minor injuries (as defined) should be treated appropriately, with early, quick and limited intervention to assist in recovery.
- The decision or not to treat an insured either within the Minor Injury Guideline or not should be made on the basis of credible medical evidence and not on speculation.
- Even those persons who otherwise might be within the MIG can be treated outside of theGuideline if there is credible medical evidence that a pre-existing condition will prevent the insured person from achieving maximal recovery from the minor injury.
Arbitrator Wilson then goes on to determine that the onus is on the insurer, not the insured, with respect to determination of a person’s injuries falling within the MIG. He states, “I accept that in the absence of clear legislative direction that would override the existing jurisprudence as to burden of proof, it remains the Insurer’s burden to prove any exception to or limitation of coverage on the civil balance of probabilities.”
The Arbitrator concludes his decision as follows:
The insurer is in effect mandated to make an early determination of an insured’s entitlement to treatment beyond the MIG. In essence, because of the necessarily early stage of the claim when the MIG is applied, the determination must be an interim one, one that is open to review as more information becomes available.
What is not is the “cookie cutter” application of an expense limit in every case where there is a soft tissue injury present. Such does not respond either to the spirit of the accident benefits system or the policy enunciated in the Guideline of getting treatment to those in need early in the claims process.
While it is quite possible that the majority of claimants can be accommodated within the MIG, averages are misleading when applied to individual cases. Each case merits an open-minded assessment, and an acceptance that some injuries can be complex even when there are soft tissue injuries present amongst the constellation of injuries arising from an accident.
The Ontario Government has made public the regulatory changes that will be made to help combat automobile insurance fraud in the province. All changes are scheduled to come into effect on June 1, 2013.
The following changes will be in effect for the Statutory Accident Benefits Schedule (SABS):
- The insurer is bound to pay only to the maximum rates established under the Guidelines for all medical and rehabilitation benefits, except for transportation.
- The insurer is allowed to have an additional Examination Under Oath of an claimant for the purpose of determining the priority of accident benefits insurers.
- An insurer will be required to give all reasons, not just a medical reason, for denying a medical or rehabilitation benefit.
- The insurer can demand:
- Confirmation in writing that the goods or services were provided to the insured person, and/or
- A statutory declaration as to the circumstances that gave rise to the invoice.
- This information must be provided within 10 business days after receiving the request; and
- An invoice is not overdue and no interest accrues on it during any period during with the insured person has not provided the information within the above timeframe.
- While the insurer is still obligated to provide regular statements to the insured as to what has been paid out on a claim, they may be required to provide additional information if the Superintendent approves a benefit statement form.
The following changes will be in effect for the Unfair or Deceptive Acts or Practices statute:
- It will be a deceptive act or practice for anyone other than a lawyer or paralegal to require, request or permit a person to sign a blank OCF form.
The legal reference for these changes are O.Reg 14/13, O.Reg 15/13, O.Reg 16/13.
The Ontario Government has announced that it will introduce regulatory amendments aimed at tackling automobile insurance fraud in the Province.
According to their website, measures will be taken as follows:
- Require insurers to provide claimants all reasons for denying a claim.
- Give claimants the right to receive a bi-monthly, detailed statement of benefits paid out on their behalf.
- Increase the role of claimants in fraud prevention (e.g. require them to confirm attendance at health clinic).
- Make providers subject to sanctions for overcharging insurers for goods and services and banning them from asking consumers to sign blank claim forms.
The entire news release can be read by clicking here.
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
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.