Monday, 2 December 2013

Scarlett and Belair MIG Decision Overturned in Appeal

In the well known Scarlett and Belair case, the claimant was injured in an accident on September 18, 2010. He took the position that he while he did suffer sprains and strains, he also suffered from pre-existing conditions and subsequent psychological disabilities that took him out of the Minor Injury Guideline. After the accident, he was diagnosed with temporal mandibular joint (TMJ) syndrome.  Later there were additional diagnoses of chronic pain and psychological impairments.

In a preliminary issue hearing, the arbitrator found that the MIG is informational and non-binding that was not altered by its incorporation in the SABS.  He also found that the insurer had the onus of proving that the claimant had sustained a minor and and was subject to the $3,500 minor injury limit. In coming to his conclusion, the arbitrator also relied upon a number of cases, his own arguments, and his own English/French translations – without providing the parties the opportunity to make submissions.

The arbitrator's decision caused considerable angst within the insurance industry and a concern that the introduction of a monetary cap for treating and assessing minor injuries would not hold - a significant change introduced by the government in September 2010. However, the Director’s Delegate has allowed the insurer’s appeal in the Scarlett and Belair decision and more importantly confirms that guidelines incorporated in the SABS are binding.  This is important to establish considering the MIG is not the only guideline incorporated in the SABS.

Some of the key points raised in the Director’s Delegate’s decision:
  • The arbitrator failed to address why he found that the claimant’s chronic pain, depressive symptoms and TMJ disorder were separate and distinct from his soft tissue injuries and were not the sequelae thereof.
  • The arbitrator never addressed the test in the SABS of whether the claimant’s impairment was “predominantly” a minor injury.  The SABS recognizes that a claimant may have mutiple injuries but that does not automatically bring he or she out of the minor injury category.
  • The arbitrator erred in finding that the burden of proof lay on the insurer to show that the claimant was subject to the MIG. The burden of proof always rests on the insured of proving that he or she fits within a scope of coverage.
  • The arbitrator was incorrect in implying that $50,000 in medical and rehabilitation expenses was some sort of default coverage.
  • The arbitrator erred in finding that “compelling evidence” simply means “credible evidence”, finding that the word “compelling” means more than “credible”.  As well, the discussion of "credible evidence" was not relevant to this case.
  • The arbitrator erred in finding that the MIG was not binding because it was only a Guideline. The Director’s Delegate found that the MIG is binding because it was issued pursuant to section 268.3 of the Insurance Act, the definition of “MIG in the SABS refers to section 268.3, and the MIG is then applied in section 18 of the SABS, thereby incorporating the MIG into the SABS by reference.
  • The arbitrator should not have been conducting his own research and relying on cases and statutory provisions that he then raised on his own after the hearing, which did not provide the parties the opportunity to respond.
The Director's Delegate remitted the matter to a full hearing before a different arbitrator, on all issues as between the parties.  The new arbitrator may still find that the claimant's impairments fall outside the definition of "minor injury" in the SABS.  It may well be that because of the claimant's other impairments (TMJ syndrome and chronic pain), an arbitrator may find that the claimant's impairment was not predominantly a minor injury.  Should that be the case, hopefully the decision will be based on the policy intent of the 2010 reforms and the SABS.

Saturday, 23 November 2013

Insurers Trying To Keep Claimants in the MIG Will Need Medical Reasons Before an IE

Insurers may be in a "Catch 22" situation in efforts to keep claimants within the limits of the Minor Injury Guideline (MIG).  Many insurers have been routinely sending claimants for an insurer examination (IE) to determine if a claimant has a minor injury and should be treated under the MIG. But according to a recent FSCO arbitration, an insurer needs to provide "medical reasons" for denying a benefit and requesting the claimant attend an IE.  The SABS require a benefit denial to trigger an IE needed to determine if the claimant belongs in the MIG but also medical reasons which insurers normally obtain through an IE.

In the decision, Kadian Augustin and Unifund Assurance Company [FSCO A12-000452] the arbitrator considered whether or not Ms. Augustin is allowed to dispute the insurer’s denial of treatment because she failed to attend an IE.  In order to make a determination the arbitrator needed to consider whether or not the IE was compliant with the SABS.

Unifund wanted to send Ms. Augustin to an IE to determine if she was within the MIG after receiving a treatment plan that, if approved, would take her out of the MIG.  Unifund provided the following notice to Ms. Augustin in their Explanation of Benefits: “Based on our review of the medical documentation provided to date, we require an assessment by an independent medical assessor, in order to determine if your impairment is predominantly a minor injury as described in the Minor Injury Guideline. Please see the Notice of Examination for further details.”

The arbitrator found that this explanation did not comply with section 38(8) of the SABS because it did not state that Unifund “believes” the MIG applies, or why.  Nor did it state the “medical reasons and all of the other reasons why the insurer considers any goods or services, or the proposed costs of them, not to be reasonable and necessary.  The arbitrator noted that it provided no reason, medical or otherwise, explaining why it refused to pay the benefit.

Health care providers have been complaining for some time that benefit denials often to not come with proper explanations regarding the reason for a denial.  The government has amended these provisions several times to make it clear that the claimant is entitled to a proper explanation.  Now an arbitrator has ruled on the wording.  The problem is that no one knows what explanation would satisfy an arbitrator.  As well, the arbitrator failed to reconcile that the purpose of the IE is to collect medical information and assist in making entitlement decisions.

The decision can be found here.

Saturday, 9 November 2013

Interim Report of the Ontario Automobile Insurance Dispute Resolution System Review

The Interim Report of the Ontario Automobile Insurance Dispute Resolution System Review is now online.  The interim report provides an overview of the history and structure of the Ontario auto insurance DRS, the structure of auto insurance dispute resolution systems across Canada and in other jurisdictions and trends in the current Ontario DRS, including outcomes of recent court and arbitration decisions.  It also makes a few recommendations and sets out a possible framework for a future DRS.

The report recommends that mediation no longer be mandatory in its current form.  It suggests that the government consider introducing a new system that consolidates the strengths of the existing mediation and arbitration processes to facilitate a more efficient model for resolving disputes.

It also recommends that the government consider that FSCO’s DRS adjudicative functions be delivered externally. The final report will address whether the adjudicative functions should be established in an independent public sector tribunal or in the private sector.

The proposed model set out in the report would provide a process that takes no longer than six months from start to finish. Cases would follow a different stream based on the benefits in dispute and the complexity of the issues involved.

The process would begin with a benefit denial.  Every Ontario auto insurance company would have to establish a formal internal review process. A claimant wishing to dispute a benefit denial would first have to meet with their insurer to clarify why they believe the insurer was incorrect and present any new information to support their claim.

If the parties cannot resolve their dispute, the claimant would then be free to file an application with the new ADR body (whether in the private sector or within a tribunal) or perhaps they could access the courts at that stage. Cases using the court option would be subject to the rules and timelines of the court system.

If the claimant chooses ADR, a case manager serving as a gatekeeper to the process would review each application to determine whether the parties are ready to proceed through the system. The case manager would determine whether there are jurisdictional issues to be addressed and whether a proper exchange of documents has taken place. The case manager would have the ability to return the application if there were any outstanding issues.

Once everything is in order, the case would immediately be assigned to an arbitrator, who would arrange a mediation session within 45 days, which would be a hybrid of the current mediation process and pre-arbitration hearing. During this stage, the arbitrator might provide a non-binding opinion on the likely outcome; in other words, the mediation session could potentially be a more evaluative process. Should the mediation fail to produce a settlement, the arbitrator would immediately schedule a hearing for the parties.

The arbitrator would also perform a triage role at this point to determine whether the case should be subject to a paper hearing, an expedited summary in-person hearing or a full in-person hearing. For a paper hearing, the parties would submit their final positions in writing along with all supporting documentation, and the arbitrator making a decision based on a document review.

For an expedited in-person hearing, the parties would submit supporting documentation, including affidavits and expert reports. Although testimony and cross-examination could take place within set time parameters, the use of expert witnesses would not be permitted. Expedited hearings would take no longer than half a day.

More complex cases, such as catastrophic impairment determinations, would be permitted to make use of expert witnesses but still would be limited to a short timeframe.

The paper hearing would take place within 60 days of the mediation, while in-person hearings would take place within 90 days.

There would be rules established, perhaps in regulations, setting out timelines, sanctions for non-compliance and other provisions to ensure the parties follow the principles set out in this report. There should be a prohibition on adjournments in all but the most exceptional cases. The length and content of expert reports would be restricted.  Each case would be decided on the merits of that case alone. Arbitrators would be required to follow the policy intent of the regulations and the Superintendent’s interpretive guidelines.

Arbitrators would have discretion to assign costs to either side when warranted. Fees may differ depending on the type of hearing. Decisions should be issued within 45 days of an in-person hearing. For paper hearings, decisions should be issued within 30 days. The process from application date to the issuing of a decision would be four and a half months for paper arbitrations and six months for in-person arbitrations.

Appeals would be heard by a single judge of the Superior Court.

Thursday, 7 November 2013

Auto Insurance Section of the 2013 Ontario Economic Outlook and Fiscal Review

The governments Fall Economic Statement included a section on auto insurance but did not include any new initiatives.   Instead, the government provided an update on current initiatives.

With respect to the government strategy to reduce Ontario auto insurance rates by 15 per cent on average within the next two years, the government gave FSCO the authority to require insurers to re-file new rates for FSCO approval. The government reports that insurers have started to file new rates with FSCO as a result of this new authority. The government also made the Superintendent of FSCO’s guidelines binding to help reduce unexpected costs.

The government expects that the January 2014 report on approved rates from FSCO will provide the first evidence that its strategy to reduce costs and rates is working.

Transforming the auto insurance dispute resolution system is another key element of the government’s cost and rate reduction strategy. The Province appointed former Associate Chief Justice of the Superior Court of Justice, the Honourable J. Douglas Cunningham, to lead a review and make recommendations on how to make this a more efficient and effective system.  Stakeholder consultations on the recommended legislative direction will be held in the coming months in preparation for the final report.

The government also committed to protecting consumers by continuing to ensure that insurer rate filings include rates that reward safe drivers and by helping to ensure that all regions of Ontario benefit fairly from cost savings.

The Ontario government is also continuing to crack down on auto insurance fraud to further benefit consumers. The government has already taken a number of actions to address key recommendations made by the Auto Insurance Anti-Fraud Task Force, such as a framework for licensing health clinics in the auto insurance system, and expanding the regulator’s investigation and enforcement authority.

FSCO has launched an Anti-Fraud Hotline will allow the public to play a greater role in combating fraud. Ontario has also added important information to the Ministry of Transportation’s Driver’s Handbook to help new drivers understand and prevent auto insurance fraud.

The government is also actively working to develop a province-wide system to oversee the towing industry. In the winter of 2014, the government will work closely with the sector, the Association of Municipalities of Ontario, the City of Toronto and other key stakeholders on the development of a proposed model. As part of this work, the government will also look at the issues of vehicle storage and collision repair practices.

In addition, the insurance industry is working to fight fraud. It recently announced the creation of Canadian National Insurance Crime Services (CANATICS), a new not-for-profit organization that will use data analytics to identify suspicious claims. The Task Force supported the use of data analytics to combat auto insurance fraud and recommended the creation of such an organization in its final report.

Insurance News - Thursday, November 7, 2013

Here are the leading auto insurance headlines from ONTARIO AUTO INSURANCE TOPICS ON TWITTER for Thursday, November 7, 2013:

Tuesday, 15 October 2013

Insurance News - Tuesday, October 15, 2013

Here are the leading auto insurance headlines from ONTARIO AUTO INSURANCE TOPICS ON TWITTER for Tuesday, October 15, 2013:

Ontario Government Consulting On Proposed Service Provider Regulations

The 2013 Ontario Budget included a commitment to introduce legislative amendments that would, if passed, "Give the Financial Services Commission of Ontario (FSCO) authority to license and oversee business practices of health clinics and practitioners who invoice auto insurers". This authority was included in The Prosperous and Fair Ontario Act (Budget Measures), 2013, which received Royal Assent on June 13, 2013. 

The legislation provides regulation-making authority consistent with recommendations made by the Automobile Insurance Anti-Fraud Task Force in 2012. 


The proposed regulations would prescribe:

- Licensing eligibility including grounds for unsuitability
- Designated principal representative eligibility requirements and duties
- Public registry information

Future proposed regulations would be expected to prescribe:

- Business/billing standards of practice
- Listed expenses (e.g. expenses covered by licensing)
- Expenses not covered by licensing
- Licence applicability
- Revocation/Suspension criteria and expedited process
- Licence surrender criteria
- Unfair or deceptive acts or practices
- Administrative monetary penalties
- Consequential amendments to the Statutory Accident Benefits Schedule (SABS) 


The Ontario government's Regulatory Registry is inviting stakeholders and interested parties to provide comments on these proposed regulations (that have yet to be made public).

The deadline for comments is November 24, 2013.

Monday, 7 October 2013

Insurance News - Monday, October 7, 2013

Here are the leading auto insurance headlines from ONTARIO AUTO INSURANCE TOPICS ON TWITTER for Monday, October 7, 2013:

FSCO Releases Usage-Based Insurance Guidelines

On October 3, 2013, FSCO released a Bulletin providing some guidance to auto insurers on the type of information that should be filed when seeking approval for a Usage-Based Insurance Pricing (UBIP) program.  For full details regarding FSCO requirement, refer to the UBIP Bulletin. 

Personal Information and Privacy Requirements

Although telematics devices do not currently have the capability to identify who is driving a vehicle at any particular time, in many circumstances (for example where a vehicle has only one listed driver), the data collected by the device may reasonably be assumed to be about that individual, with the result that the data is personal information as defined in PIPEDA.   However, FSCO has taken the position that telematics data should be treated as personal information even if it is not about the driving behaviour of any one identifiable individual. 

Personal Telematics Data: Insurer Transparency and Consumer Consent

UBIP programs must be voluntary and enrollment must include the express, informed consent of the policyholder to the collection, use and disclosure of personal information by the insurer or third party provider.  Any personal information collected through a UBIP program, or its accompanying devices or software, should not be disclosed to any other party unless expressly consented to by the person or as required by law.

 Drivers should be able to enroll in a UBIP program without being required to share their personal information for non-UBIP purposes (e.g., marketing, offering of additional services such as vehicle location services or assistance in emergency situations).

Insurers should, where possible, facilitate drivers using their personal UBIP data for the purposes of entering into a contract with another insurer including enrolling in another insurer’s UBIP program.  
 
A consumer’s enrollment in a UBIP program involves the agreement by the consumer and insurer to additional legal rights and obligations outside of those in the standard auto insurance policy.  In Ontario the mechanism for amending the standard auto policy is by way of an endorsement form which must be approved by the Superintendent. 

 Insurers may also be required to provide the Superintendent with any advertising or promotional material proposed for use in relation to their UBIP programs to ensure that it is clear, fair and not misleading.
Complaints, Inquiries and Customer Support

Insurers must be sure to provide adequate customer service support  and outline appropriate mechanisms, enquiry management, and resolution systems to respond to customer questions, concerns and disputes.

Driver Education and Transparency in Rating and Risk Classification Systems

To encourage safe driving and ensure transparency, it is important that the rating model for a UBIP program be clearly communicated to the consumer at all times, beginning prior to enrollment and continuing through to each policy renewal. The impact that a consumer’s driving data has on the premium must be clearly articulated including a clear explanation of how to qualify for a discount, the period being measured to calculate the discount, the maximum or minimum of that discount, and regular feedback on driving habits to the consumer.

Changes in Rating

Consistent with the existing policy renewal process in Ontario, any change in rating on a policy must be done in accordance with s. 236 of the Insurance Act.

Limitations on Collection and Use of UBIP Data for Insurance Purposes

UBIP programs, including program-provided devices and applications, should collect and use UBIP data solely for discount-setting purposes, and not to decline, cancel or refuse to renew risks or to confirm rating criteria currently used.

General Rate-Filing Information
 

Any UBIP program must be filed and approved by the Superintendent. It is recognized that there may be no Ontario-specific data to provide in a filing.  However, FSCO is supportive of innovation and, as with other rating factors new to the market, is willing to review data and the amount of the discount charged in other jurisdictions.UBIP-related rates and risk classification system elements must be just and reasonable and otherwise satisfy the statutory standards applicable to all rates and risk classification systems.

UBIP Program Costs and the Impact on Insurer Expenses

To encourage drivers to participate, insurers should cover all costs of enrolling in a UBIP program including the cost of any device installation and any ongoing costs of operation or maintenance. Insurers must clearly demonstrate the up-front or start-up costs associated with developing and introducing a UBIP program, as well as all ongoing maintenance and other expenses associated with offering the program, including but not limited to all costs associated with the UBIP device, data transfer and analysis, marketing and any third party provider contracts.

Reasonability of UBIP assumptions and the provision of adequate support   

Proposed UBIP models may first be reviewed and approved by FSCO in principle, following which an insurer would make a formal filing for Superintendent’s approval. Approval of the filing could be made conditional on further filings being required at scheduled intervals to provide the necessary continued support for the UBIP rating system.

General Data Considerations: accuracy, security, storage, at termination 

Before any UBIP data is used for rating purposes, reasonable efforts must be made to ensure that the data is accurate.

Insurers must also ensure that the data capture, transmission and analysis are all done within a secure environment.

Insurers and third parties should delete or anonymize personal information once there is no clear business need to retain the data.  

Insurers must ensure that no further data is received or accessed after a consumer terminates participation in a UBIP program or terminates the policy.

Roles and Responsibilities: Insurers and Third Party Providers 
FSCO expects that insurers will have written contracts with each third party provider to confirm:
  • the provider’s ability and commitment to ensure a level of personal information protection equal to or greater than that expected of the insurer, and to comply with all applicable laws and regulations,
  • that the service provider has the required service capability, and
  • that succession issues are addressed to ensure a smooth transition when ending or varying an agreement with a provider.

Monday, 23 September 2013

Mike Colle Introduces Bill For New Drivers And Minor Accidents

Liberal MPP Mike Colle who is familiar with the auto insurance file while Parliamentary Assistant to former Finance Minister Greg Sorbara introduced a Bill, the Insurance Amendment Act (Minor Accidents and New Drivers), 2013 on September 18, 2013.   

Bill 100 if passed with require that a risk classification system used by an insurer to determine rates for auto insurance could not consider minor accidents and would provide for lower rates for new drivers by crediting new drivers, in certain circumstances, with additional years of driving experience.

Minor accidents are accidents that result in $2,500 or less in damages, no injuries or death, and that did not result in an insurer making any payments that were not fully reimbursed by an insured driver.

A new driver is disqualified from receiving additional years of credit in a number of circumstances, including if the driver has been found to be more than 25% at fault in a claim arising from an accident, has been convicted of certain driving offences or has had his or her driver’s licence suspended for non-payment of certain fines.  The Bill is similar to an amendment passed in New Brunswick for new drivers called "First Chance" as part of reforms in 2005.

The Bill would reduce rates for new drivers and would prevent rate increases for anyone at-fault in an accident and paid the cost of repairs out of pocket as long as the repairs are less than $2,500.

On August 24, 2013, the Minister of Finance, the Hon. Charles Sousa, issued a policy statement that directed FSCO to review ways to “treat first-time drivers fairly” and to study the mandatory collision reporting threshold as a “potential cost reduction” initiative.