Ontario insurance regulator outlines insurers’ rights and responsibilities in curbing “questionable or abusive claims”

Ontario’s insurance regulator, the Financial Services Commission of Ontario (FSCO), has issued a bulletin outlining an insurer’s “rights and responsibilities to challenge questionable or abusive claims.”
The bulletin comes in the wake of the province’s auto insurance reforms, implemented on Sept. 1, 2010.
“FSCO is monitoring on an ongoing basis the interpretation and application of the SABS and associated guidelines by its stakeholders, with a view to identifying and responding to actions that are inconsistent with the recent auto reforms,” the regulator says in its bulletin.
“FSCO recognizes that an overwhelming majority of stakeholders are fair and responsible participants in the auto insurance system. However, FSCO is also aware that a small group of service providers and representatives continue to abuse the system.”
FSCO outlines several areas of concern, including:
1) It notes the new SABS introduced an interim Minor Injury Guideline (MIG), which defines “minor injuries” as one or more of a sprain, strain, whiplash associated disorder, contusion, abrasion, laceration or subluxation and includes any clinically associated sequelae to such an injury.
All persons with minor injuries fall under the MIG, with limited exceptions, including if compelling evidence demonstrates that a pre-existing condition will prevent that person from achieving maximal recovery if he or she is limited to MIG treatment.
“It appears that some providers are requesting approval for treatment of minor injuries on a Treatment and Assessment Plan (OCF-18) rather than providing pre-approved treatment under the MIG by submitting a Treatment Confirmation Form (OCF-23),” FSCO notes.
“The auto reforms are still fairly new and not all providers are familiar with the minor injury definition and the MIG.
“In particular, not all providers are aware that the existence of other injuries and conditions will not necessarily bring a claimant outside the MIG if the predominant impairment falls under the minor injury definition.”
Insurers have a role to educate health care providers on the new MIG, FSCO noted, adding most already perform this role.
2) FSCO notes a few health care providers are flooding insurers with treatment plans.
“It appears that a small number of providers engage in the practice of flooding insurers with multiple versions of similar or identical treatment and assessment plans (OCF-18s) in an apparent attempt to overwhelm adjusters,” the FSCO bulletin says. “In many cases it appears that the objective is to cause adjusters to miss the approval timelines set out in the SABS.
“This type of behaviour is clearly inappropriate.”
FSCO notes an insurer is not obligated to undertake an assessment for each treatment or assessment request.