Too many disincentives in Ontario’s AB system to help people get better: SIU fraud investigator

Treatment providers and ancillary businesses have a vested interest in a person’s auto-related injuries, leading to disincentives in the system to get people better, according to Bob Reinhart, SIU investigator at RBC Insurance.
Speaking to people attending the Annual Toronto Fraud Forum on Sept. 30, Reinhart said too many people in the accident benefits insurance system see the claims resolution process as a kind of cash cow.
Even if the injured party gets better, all of the income that treatment providers earn on the basis of the person’s injury does not get returned to the insurers that paid the claim, said Reinhart, adding that his views were not necessarily those of RBC Insurance.
“From a fraud point of view, what I believe is driving a lot of fraud we are seeing is that money is too easily accessible,” he said.
When Ontario’s auto insurance regulator, the Financial Services Commission of Ontario (FSCO), came out with the pre-approved framework guidelines in 2003, the intent was to use these guidelines when handling WADs (whiplash-associated disorders), Reinhart said.
However, people are not using it exclusively for this purpose, and this is an area where things are now out of hand, he noted.
In its 2009 recommendations, FSCO noted that: “Following the implementation of the PAF (Pre-approved Framework) Guidelines in 2003, it was anticipated that a pre-approved treatment approach with block fees would help stabilize overall treatment costs by providing streamlined access to treatment for whiplash associated disorders, which FSCO has been told constitutes the largest group of auto accident injuries.”
Soft tissue injuries occur in about 90% of motor vehicle accidents, and 85% of those are whiplash-related injuries, said Reinhart, adding these were not hard figures.
Reinhart said FSCO’s intent was for PAF not to be used if the injuries fell outside of the soft-tissue and whiplash-related categories, but somehow that didn’t happen.
Despite the PAF guidelines, the costs associated with the accident benefits, particularly medical rehabilitation benefits and assessment costs, have continued to rise, Reinhart said, citing FSCO.