Tag Archives: fsco

Practical Strategies Webinar: Auto Insurance Law Impacting You and Your Clients

The Practical Strategies webinar aired on April 30, 2013.

This webinar will update you on how lawyers and health care providers are coping with the evolving challenges of working in the constantly changing auto insurance system. You will learn strategies that will benefit you and your clients, including:

  • Establishing “incurred expense” and “economic loss” in attendant care claims.
  • Recent developments in catastrophic impairment.
  • Common pitfalls in clinical note taking and report writing.
  • Preparing for giving evidence in the Courtroom.

[youtube]http://www.youtube.com/watch?v=5UoH38vOgvQ[/youtube]

 

No need for review of catastrophic provisions

An auto insurance industry review of catastrophic impairment provisions is unnecessary at this time, Toronto critical injury lawyer Dale Orlando says in Law Times.

The provincial government has reopened renewed consideration of the provisions by starting stakeholder consultations not restricted to medical experts as was the case with last year’s review by the Financial Services Commission of Ontario, the article says.

“Where’s the fire?” Orlando, partner with McLeish Orlando LLP, asks in the report.

“They’re searching for a solution to a problem that simply doesn’t exist. Around one per cent of claims are deemed catastrophic. On a claim-by-claim basis, it’s a lot of money, but in the scheme of things, there’s no evidence that there’s been an upswing in costs.”

The Law Times article also discusses an Ontario Trial Lawyers Association advisory sent out in March that alleged the Insurance Bureau of Canada is misinforming officials about insurance premiums, claims costs, and profits.

The Insurance Bureau of Canada responded by publishing an actuarial analysis from JF Cheng and Partners on March 28, and then a KPMG LLP-authored analysis of Ontario private passenger automobile insurance results for 2008-12, the article says.

Source: AdvocateDaily.com

Pastore v. Aviva: A Single Mental & Behavioural Disorder is Sufficient for Catastrophic Impairment

The Ontario Court of Appeal released the Pastore v. Aviva decision today and decided that a marked impairment of a single area or aspect of functioning is enough to designate a person as catastrophically impaired.

In the decision delivered by Justice Feldman, the Court concluded that the Director’s Delegate’s decision to this effect was a reasonable one:

In my view, the decision of the delegate, in which he concludes that the use of “a” in the definition of “catastrophic impairment” in cl. (g) refers to a single functional impairment due to mental or behavioural disorder at the marked level, constituting a catastrophic impairment, is a reasonable decision.  The reasoning process was logical and transparent and the result is within the range

What is also very important is that the impairment does not have to be due “solely” to the mental or behavioural disorder. The marked impairment can be caused by a combination of mental and behavioural disorder as well as physical causes of pain:

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60-Day Failed Mediation Motions: Insured Victims Win Decisively

There is good news to report to anyone who has unjustifiably been denied access to any statutory accident benefit that they have applied for or has had to deal with a dispute over the determination of catastrophic impairment.

Most people reading this blog will be familiar with the dispute resolution procedure under the Insurance Act.  Most people will recognize that the procedure is badly broken.  Before a dispute can proceed to Court or to a binding Arbitration, a mediation must be held at the Financial Services Commission of Ontario.  If the mediator is unable to resolve the dispute, only then are you able to proceed to a final determination of the issue.  The difficulty is that mediations are being scheduled more than a year from the filing of an application in many instances.

Now for the good news.  Justice Sloan ruled on February 8, 2012 in the case of Cornie v. Security National, that section 19 of the Dispute Resolution Practice Code requires FSCO to conduct a mediation within 60 days of the filing of the Application.  If FSCO is unable to schedule a hearing within this time frame, the mediation is deemed to have failed and the claimant can proceed to a final determination.

In rejecting the defence arguments in the case, Justice Sloan says “The insurance companies take the position that the accident victims must simply wait.  To entertain this argument could mean that an accident victim might have to wait 100, 300 or 500 days for mediation.  I find that submission preposterous.”

Alarming Recommendations for the Seriously Injured

The Financial Services Commission of Ontario (FSCO) Panel selected to review the definition of Catastrophic Injuries has released their report.

To those consumers not familiar with this, see my previous blog “Catastrophic Impairment under a Microscope.” It was anticipated that the review of the definition would give rise to maintaining or granting greater access to medical and rehabilitation benefits to those suffering catastrophic injuries. The last set of changes made by the Ontario Government in September 2010 saw many accident benefits slashed in half or eliminated for the less seriously injured.  These cuts were made in order to ensure that the system was financially able to protect those suffering from the more disabling catastrophic injuries. Therefore it was extremely alarming to see that the FSCO Review Panel has  recommended new changes which will make it more restrictive for the seriously injured victims to meet the catastrophic definition.
If implemented, a large portion of these victims will be denied the designation and suffer greatly with the reduced benefits. The changes prevent the injured person from having psychological injuries combined with physical injuries when conducting the assessment. As well, they propose to get rid of the GCS score as a designator for those suffering brain injuries. The brain injury victim will no longer be able to qualify based on the early GCS score, but would rather be subject to a longer and more detailed assessment. An assessment which will delay benefits from flowing and costs significantly more.
This means that many people who suffer serious brain impairments, psychological injuries and physical injuries will be denied access to meaningful benefits in the future. The funds normally spent to get the seriously injured victims better or allow them to live with dignity will simply remain within the insurance companies. Of course, this will in turn increase the profitability of the insurance industry and put higher demands on the public health system.

However, the panel is only the first step in the review. The recommendations are not yet law. FSCO and the Government also requested submissions from the legal and medical communities. The deadline of May 13, 2011 has now passed. The response by these communities has been loud and clear. The recommendations are premature, flawed and ought not to be implemented.

A panel of prominent medical specialists in field of traumatic injuries have taken objection to the recommendations. This panels’ review was endorsed by the Alliance of Community Medical and Rehabilitation Providers of Ontario. The medical outcry is of no surprise, since the recommendations now being made are at complete odds with a 2001 Medical Panel Review. The September 2001 Review was supported by the insurance, legal and medical communities.
The major legal organizations have also stood up and indicated that these recent recommendations ought not to be implemented. They include the Ontario Bar Association, The Advocates’ Society, and the Ontario Trial Lawyers Association.

Based on the resounding objection, one can not imagine the Government giving any weight to the proposed recommendations. What is interesting is that in the submission made by the Alliance, they understand that over half of the panel making these recommendations had been at one time consultants with the Insurance Bureau of Canada.
What is really driving these recommendations?
Voice your Opposition to the Panel’s Recommendation and put people before profits. Send an email to your local MPP today before it is too late!

Catastrophic Definition is now under the Microscope: This review will have a serious impact on the Disabled !

The Financial Services Commission of Ontario (www.fsco.gov.on.ca) has now commenced a review of the “Catastrophic Definition”. The outcome of this review will have a dramatic impact on the victims who suffer severe disabilities in car crashes. For those deemed to be “catastrophic”, it can mean the ability to access essential services to live independently and with dignity. For those that are not, it can mean a life of limited help, despair and a stalled recovery. The stakes are very high!
The FSCO has now appointed an Expert Medical Panel to make recommendations regarding the definition and the assessment process. Careful attention will be made on people suffering traumatic brain injuries, paralysis, spinal cord injuries, severe mental and psychological disorders, and those suffering from multiple broken bones.
Many lawyers, doctors, rehabilitation professionals and treating providers are looking forward to the review. It is hoped that it will finally address the many holes that are within the system. Holes that have resulted in many seriously disabled victims being left out in the cold when it comes to basic care services and rehabilitation treatment. Treatment that will help them get better and integrated back into society and the workforce.

The last changes made by the Ontario Government to the insurance system was in September of 2010. These changes saw a drastic reduction in benefits to those suffering less severe injuries. The intent was to eliminate and drastically reduce benefits flowing to people suffering minor injuries. By cutting the flow, it would mean insurance companies would not have to raise auto insurance premiums to the driving public. It was also seen as a way of making sure greater benefits could flow to the more seriously disabled victims. As some would say, soft tissue injuries would have to take a back seat to the seriously injured.

Although the review process is to look at ways of making the present system better and more efficient, some fear that it will be used as a vehicle by the insurance industry to make it harder for people to be deemed “catastrophic”. This of course would mean people who otherwise would have up to two million in benefits available to meet their needs, would be reduced down to a bare bones package that is exhausted normally with one to two years. This of course cannot be the intent of the review. The review ought to ensure greater access is given to the seriously injured. Substantial savings have already been afforded to the insurance industry as cited in my previous blogs. To now go after the seriously injured and seek to reduce their benefits is just wrong.

Many are confident that the medical panel, FSCO and the Ministry will ensure these seriously injured persons are protected. An expansive approach with the definition must be done. A definition that recognizes all serious injuries. A definition that takes into consideration the collective impact of all injuries on the disabled. It should never be forgotten that there are no windfalls that happen when one is deemed “catastrophic.” Even if someone is found to suffer a catastrophic injury, they still must prove the need for benefits. It simply does not mean money falls on to their lap and they keep it. The money goes to rehabilitation, home modifications, mobility aids, and attendant care. The disabled person still must prove they need the services ( the wheelchair ramp, the wheel chair lift, the helper to get dressed etc.). If they don’t prove it, they don’t get it. If the definition is expanded, it simply means those who need it can access it beyond the temporal and monetary caps of $3,500 or $50,000 as set out in my previous blogs.

If the panel or FSCO or the Ministry seek to tighten up the definition, which would be contrary to the intent of the review, then many severely disabled individuals will be shut out from accessing the rehabilitation and medical help needed to live with dignity and independence. Of course further restriction would simply mean greater savings to the insurance industry. This time however, it will be on the backs of the severely disabled.