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Posts Tagged ‘rehabilitation’

Anti-Fraud Task Force Steering Committee is Seeking Public Comment

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.

Ontario Court of Appeal: It is possible to work and be entitled to a Non-Earner Benefit

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:

[43] 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.

[44] 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.

Health Care Providers: Congratulations, You’re Getting A Raise!

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.

2012 FSCO Fee Guidelines

Applying to Wrong Insurer is a Reasonable Excuse for Delay in Applying to Correct Insurer for Accident Benefits

A recent arbitration decision by the Financial Services Commission of Ontario (FSCO) confirms that an insurer cannot deny accident benefits if the application is significantly delayed because the claimant applied to the wrong insurer first.

In the decision, Egal and Economical [FSCO A10-004057] Arbitrator Judith Killoran concluded that the Applicant, Roda Egal, had a reasonable excuse for the delay in applying for accident benefits with the Economical Insurance Company, because Ms. Egal had originally applied to another insurance company (American Assurance) who was handling her claim.  Economical did not take timely steps to request information to corroborate her claim, but rather simply maintained their position that she had not applied for accident benefits within the timeframes outlined in the Statutory Accident Benefits Schedule (SABS).

Furthermore, Arbitrator Killoran ordered a special award in the amount of $5,000.00 against Economical for its unreasonable position.  As stated in her decision,

I find no merit in Economical’s position that it had no responsibility to adjust Ms. Egal’s file until receiving a reasonable explanation for her delay in applying. Economical received a reasonable explanation for the delay. Economical was also aware that documentation had been sent to the wrong insurer and persisted in refusing Ms. Egal’s claims long before it had received her file.
I find that Economical failed egregiously in its responsibilities to its first party insured, Ms. Egal. It did not follow up expeditiously in obtaining her file from American Assurance and it made decisions about her entitlement in its absence. No attempts were made to evaluate the merits of Ms. Egal’s claims. I find that Economical unreasonably withheld the payment of benefits to which Ms. Egal was entitled. Consequently, I find that Ms. Egal is entitled to payment of a special award fixed at $5,000, inclusive of interest. 

This decision can be read in its entirety by clicking here.

Medical and Legal Communities Speak Out Against Proposed Changes to “Catastrophic” Definition

The Ontario Trial Lawyers Association (OTLA) and Alliance of Community Medical and Rehabilitation Providers has launched a massive media campaign against proposed changes to the definition of a catastrophic impairment for victims of motor vehicle accidents.

The changes being considered, already posted on our blog (you can access this blog article by clicking here), would significantly reduce the number of accident victims with serious injuries from having their claims deemed as catastrophic.

For example, a paraplegic who is able walk just a short distance would not be deemed catastrophic, even though their medical and rehabilitation needs would be very significant.  Under the proposed changes, these individuals would have to pay for any treatment beyond the non-catastrophic medical and rehabilitation benefits limit of $50,000.00.  Most rehabilitation services are not covered under OHIP.

If an individual’s injuries are deemed “catastrophic” their accident limits change as follows:

  • Medical and Rehabilitation benefits increase from $50,000.00 over 10 years to $1,000,000.00 over a lifetime
  • Attendant Care benefits increase from $36,000.00 over two years (to a maximum of $3,000.00 per month) to $1,000,000.00 over a lifetime (to a maximum of $6,000.00 per month)
  • The right to the services of a case manager to help coordinate their medical and rehabilitation needs
  • Housekeeping and Home Maintenance benefits (available for non-catastrophically injured victims, but only if optional benefits were purchased under their insurance policy)

The advertisement will run in major newspapers across Ontario over the course of this week and the next.

Please click on the link below to see the advertisement.

Catastrophic Injuries Media Campaign Ad

These changes would be in addition to the massive cutbacks to accident benefits implemented in September 2010.  Auto insurers are currently reporting significant profit margins.

We encourage all concerned individuals to contact their local Member of Provincial Parliament (MPP) immediately to express their concerns with these proposed changes.

Toronto Star: Auto Insurers Routinely Deny Treatment Plans

An article in today’s Toronto Star addresses the issue of an increase in denials of treatment plans by auto insurers for people who are injured in automobile accidents.

It is reported that the Ontario Government intends to hold public hearings on auto insurance.

You can read the entire article by clicking here.

FSCO Releases 2012 Draft Statement of Priorities

The Financial Services Commission of Ontario (FSCO) has released its draft Statement of Priorities for 2012.

Many of the priorities focus on changes to the auto insurance sector.  They include the following:

  • Continuing to assess the extent of auto insurance fraud and consider the recommendations of the task force when their report is released in the Fall of 2012;
  • Exploring ways to utilize the Health Claims for Auto Insurance (HCAI) system to detect and prevent fraud;
  • Implement auto insurance recommendations made in the Auditor General of Ontario’s 2011 Annual Report;
  • Undertake long-term auto insurance reform initiatives, including review of the Minor Injury Group (MIG) protocol and changes to the catastrophic impairment criteria;
  • Reduce the mediation backlog; and
  • Conduct market conduct audit reviews of compliance with the 2010 auto insurance reforms including Statutory Accident Benefits;

The entire draft Statement of Priorities can be read by clicking here.

The Attendant Care Needs Assessment (Form 1): It is what it is

In a recent Financial Services Commission of Ontario (FSCO) Arbitration ruling, Costel Sicoe and Jevco Insurance Company [FSCO A08-001173], Arbitrator Susan Sapin confirmed that the hourly rates indicated on the Attendant Care Needs Assessment (Form 1) are the rates which are to be used by insurers for paying the benefit.

Mr. Sicoe was catastrophically injured in a motorcycle accident on June 15, 2006.  As a result of this accident he required round-the-clock attendant care.  Jevco paid the attendant care to the maximum of $6,000.00 per month.

However, in February 2009 Mr. Sicoe moved to Romania.  Jevco reduced the monthly attendant care payments based on an argument that the basic supervisory care amount of $7.75 per hour is based on the minimum wage in Ontario at the time of the accident, but in Romania the minimum wage was $1.30 per hour.  Jevco paid $1.30 per hour for the basic supervisory services.  This resulted in Mr. Sicoe being paid less than the $6,000.00 per month that he was entitled to in accordance with the Form 1.

Arbitrator Sapin confirmed the interpretation of an “incurred expense” from previous case law:

It is well-established that an applicant need not actually receive the items or services claimed in order to be entitled to an expense. To do otherwise would allow the insurer to set up the inability of an insured to pay for a benefit as a shield from its obligation under the policy of insurance. It is sufficient that the reasonableness and necessity of the service be established and that the amount of the expenditure can be established with certainty.

This decision further confirms that insurers are bound to pay attendant care benefits in accordance with the Form 1 and that they do not have the discretion to pay below the rate established by the Form 1.  To that end, Arbitrator Sapin stated the following:

I note that the most recent Attendant Care Hourly Rate Guideline, dated June 2010 and available on the Commission website, establishes the maximum expense that automobile insurers are liable to pay under the Schedule for attendant care services (for accidents after September 1, 2010). The Guideline also states that “Insurers are not prohibited from paying above the maximum hourly rates established in this Guideline.” It does not say, however, that insurers can pay less.

State Farm to pay $23,000.00 Special Award for Unreasonably Withholding IRB’s

NOTE: This decision was overturned on appeal on October 1, 2012

In the decision Marcia Henry and State Farm Automobile Insurance Company [FSCO A09-000213] FSCO Arbitrator Denise Ashby ordered the insurer to pay a claimant’s income replacement benefits (IRB) with interest. The insurer was also ordered to pay a special award of $23,000.00 for unreasonably withholding the benefit.

Marcia Henry was a full-time emergency triage nurse in a hospital. The medical experts identified that she was only capable of engaging in sedentary work. Despite that, State Farm terminated her income replacement benefits prior to the 104-week mark, taking the position that she did not suffer a substantial inability to perform the essential tasks of her pre-accident work.

The Arbitrator also considered Ms. Henry’s entitlement to IRB’s after the 104-week mark, when the eligibility criteria changes to having to suffer a complete inability to engage in any employment for which she is reasonably suited, based on education, training and experience.

Although Ms. Henry took courses to upgrade her resume following the accident, it was determined that she still remained competitively unemployable when compared to her pre-accident job. The Arbitrator noted that, “It is unrealistic to believe that a woman of Ms. Henry’s age, disability and expected level of income would be hired over similarly educated, healthy and younger candidates who would likely have lower salary expectations.”

The Arbitrator went on to state that,

The accident occurred in February 2007. For the majority of her studies Ms. Henry was not engaged in employment and was able to work at her own pace. Notwithstanding this flexibility, it took four years to complete her degree. While Ms. Henry’s extensive experience and academic success might appear to make her an attractive candidate for employment as a nursing or public health instructor, her lack of teaching experience and accommodation requirements negate this. I accept that Ms. Henry enrolled in post-graduate studies as part of a career plan which would have seen her transition from the physically demanding role of emergency department nurse to a more sedentary role in public health. However, the injuries sustained in the accident prevented her from implementing her plan. Therefore, I find that Ms. Henry is entitled to post-104 week income replacement benefits.

With regard to a special award, the Arbitrator made the following comments:

State Farm stubbornly held to the opinion of its medical assessments of 2007 that Ms. Henry was not substantially disabled. Notwithstanding there was compelling evidence that Ms.
Henry continued to require significant medical intervention including shoulder surgery in June 2009.

An insurer has a continuing obligation to adjust a claim. State Farm failed to meaningfully revisit its opinion as the 104 week period elapsed and Ms. Henry had not returned to work.

I find that State Farm unreasonably withheld income replacement benefits from Ms. Henry and as a consequence she is entitled to a special award. As State Farm essentially abdicated its responsibility to adjust the file in respect of the post-104 week period, the award should be at the higher end of that available.

The full decision can be read by clicking below.

Henry and State Farm.

Smitiuch Injury Law Wins FSCO Decision: Swerving on a Bicycle to Avoid Vehicle is an “Accident”

Smitiuch Injury Law recently won an arbitration decision, DiMarco and Chubb Insurance Company, at the Financial Services Commission of Ontario (FSCO) regarding what is deemed to be an “accident”.

Marilena DiMarco was riding her bicycle on a training ride for a charitable event when she and her group went through a town that was having a street festival.  Because the street was closed the group rode their bicycles on the sidewalk.  A van was parked half-way on the sidewalk.  When Ms. DiMarco swerved to avoid the van, she lost her balance and fell, hitting the van with her hand in the process.  Chubb Insurance refused to accept the incident as a “motor vehicle accident” as defined in The Insurance Act and Statutory Accident Benefits Schedule (SABS) and refused to pay for badly-needed treatment and other accident benefits.

Arbitrator Deborah Pressman stated the following:

In this case, Ms. DiMarco was compelled to manoeuvre on the sidewalk around a vehicle that was parked in her way.  This automobile set in motion a chain of events directly resulting in Ms. DiMarco’s fall from the bicycle.  There was no intervening act that caused Ms. DiMarco to fall.  There were no other impediments around the automobile or near Ms. DiMarco.  Therefore, there was a direct and proximate cause between the “use or operation” of the automobile and Ms. DiMarco’s injuries.

Peter Cho, an associate lawyer at Smitiuch Injury Law Professional Corporation, represented Ms. DiMarco at the arbitration hearing.  He was assisted by Chris Jackson, Accident Benefits Manager.

The decision can be read by clicking on the attached.  DiMarco and Chubb Insurance Company of Canada FSCO Decision A10-003967

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