Arbitrator calls on insurers to do “more careful” review of their medical reports

An Ontario arbitrator says insurers need to do a “more careful” review of their medical reports, in light of a case in which an insurer relied on medical assessments that the arbitrator ultimately found to be wrong or inconsistent.
“It is not unreasonable of the insurer to withhold the payment of [income replacement benefits] to Mr. Carr based on its deference to the medical opinions of its own assessors,” Financial Services Commission of Ontario (FSCO) arbitrator Judith Killoran wrote in Phillip Carr and TD General Insurance Company. “However, it is hoped that insurers will aspire to a higher standard resulting in a more careful review of their medical reports, comparing and contrasting them with those of their insured, so as to guarantee the utmost fairness in their handling of claims.”
Killoran found Carr was entitled to receive approximately $36,000 in income replacement benefits based on rib and back pain he suffered after a motor vehicle accident in Toronto in 2008.
The arbitrator criticized the reports by the insurers’ medical assessors, which repeatedly failed to mention Carr’s reports of back pain even though such pain found its way into the ambulance and other medical reports.
The disability should have been the focus in determining IRB benefits, not the actual diagnosis, Killoran found.
She went on to note the insurers’ assessors did not ask Carr to perform activities that he would have routinely performed as part of his work as a manual labourer.
Without this information, the insurers’ medical assessors had no basis upon which to find that Carr could indeed have performed his daily work routines, which the insurer argued.
Carr asked the arbitrator for a special award to be made against the insurer for unreasonably withholding his IRB benefits.
Carr did not grant the special reward, on the basis that the insurer did at least order the assessments, even though they later proved to be of questionable value.