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Tuesday, December 12, 2017

 
 
 

 
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Posts Tagged ‘rehabilitation’

Judge Declares Mediation “Failed” if not Mediated within 60 Days

A decision from the Superior Court of Justice of Ontario was released that declares a mediation by the Financial Services Commission of Ontario (FSCO) failed if it has not been mediated within 60 days of the application being submitted.

In Cornie v. Security National [2012 ONSC 905], which was heard with three other similar cases, Justice J.W. Sloan renders the following decision:

It currently appears that FSCO’s Dispute Resolution Services’ Mediation Unit is functioning without timelines and has been doing so for years.

The SABS [Statutory Accident Benefits] are for the benefit of injured motor vehicle victims and are often required in a timely fashion.

It makes perfect sense that the legislation and the DPRC [Dispute Resolution Practice Code] refer to a 60 day time limit to deal with such disputes.

In contrast to the injured victims, insurance companies are not in a vulnerable position.  While there is nothing to suggest that these insurance companies are in any way responsible for the delay in mediation, there is no evidence that the delay in mediation is of any real consequence to them.

Justice Sloan found the insurance companies’ postion that accident victims must simply wait to be “preposterous” and suggests that FSCO can continue to try to comply with the 60 day period or seek a change and/or ask for some legislative direction to extend the 60 day period in appropriate circumstances.

It remains to be seen if this motion decision will be appealed.

Toronto Star Article on Lengthy Wait Times at FSCO

The Toronto Star has published an article identifying the lengthy wait times at the Financial Services Commission of Ontario (FSCO) for mediations of accident benefits denied by insurance companies.

Our firm’s own Michael Smitiuch was interviewed and quoted in the article.  He identifies the significant hardship that these delays often mean for clients and notes this to be an access to justice issue.

To read the Toronto Star Article, click here.

The Toronto Sun explores the human side of the “catastrophic” debate

A story written in the Toronto Sun looks at the current debate over the definition of catastrophic impairment and details the ongoing battles of Robert Kusnierz, whos recent Ontario Court of Appeal win supported the combining of physical and psychological impairments for determining a whole body impairment.

You can read the article in full by clicking here.

CBC Toronto Exposes Increase in Auto Insurance Treatment Denials

The Canadian Broadcasting Corporation (CBC) in Toronto recently aired an expose on the increase in denials for medical and rehabilitation treatment by Ontario’s no-fault automobile insurers and the significant delay in obtaining justice for unreasonable denials.

To read the article and watch the archived video, click here.

Ontario Court of Appeal: Desbiens Stands

The Ontario Court of Appeal has reversed the decision of Kusnierz v. Economcial Insurance.

In the Kusnierz v. Economical Insurance decision, Justice Lauwers had determined that it was not permissible to assign percentage ratings in respect of psychological impairments under 2 (1.1)(g) of the Statutory Accident Benefits Schedule (SABS) and combine them with percentage ratings in respect of Kusnierz’s physical impairments under Clause 2(1.1)(f) of the SABS for the purposes of determining whether an individual was catastrophically impaired.

Justice Lawers reviewed the earlier decision of Justice Spiegel in Desbiens v. Mordini but respectfully came to a different conclusion.  Justice Lauwers did not review any of the FSCO decisions on the issue.

This means that both physical and psychological impairment percentage ratings can be combined when determining a catastrophic impairment.

Toronto Star: Fight fraud, but not at the expense of legitimate claimants

The Toronto Star has published an article about the need to find balance between fighting fradulent accident benefits claims and providing necessary goods and services for legitimaely injured clients.

You can read this article by clicking here.

Ontario’s Auditor General Calls for Changes in Auto Insurance Sector

Ontario’s Auditor General released their annual report.  Included in their findings was a question regarding why auto insurers are allowed a 12 percent rate of return when the economy has been so slow.  It also calls on the Financial Services Commission of Ontario to put more resources into elminating the backlog of mediations and arbitrations.

You can read the entire report by clicking here.

Ontario Auto Insurance Anti-Fraud Task Force Releases their Interim Report

The Ontario Auto Insurance Anti-Fraud Task Force has released their interim report.

You may read their report by clicking 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.

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.”

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