Cost of Goods Guideline now available
The Guideline will be effective for any Treatment and Assessment Plan (OCF-18) and Auto Insurance Standard Invoice (OCF-21) submitted in respect of a medical or rehabilitation benefit claim made under the new SABS or old SABS, after the date of publication in the Ontario Gazette. (Jan.14th 2011)
This Guideline has been developed as a result of a recommendation by the Auto Insurance Anti-fraud Task Force in its interim report regarding measures that should be undertaken as soon as possible. Consistent with Ontario’s crackdown on criminal and opportunistic automobile insurance fraud, the interim report suggested the creation of “a guideline to address the issue of insurers being invoiced for medical devices at prices considerably higher than their normal retail value”.
FSCO’s guideline provides direction concerning the appropriate interpretation of the term “reasonable” in these sections.
“For the purposes of this Guideline, the retail price is the lowest price, including delivery charges (if delivery is required), duties and taxes, that would be payable by or on behalf of an insured person to acquire an item of goods from a source that is available to a member of the general public in Ontario,” the guideline states. “Where a retail price exists for an item of goods, a ‘reasonable’ expense for that item…is that retail price, or the price actually paid or payable by or on behalf of the insured person to acquire the item, whichever is lower.”
…in the event of a dispute over whether an expense for an item is ‘reasonable,’ the onus is on the insurer to provide reasonable evidence of the retail price of the item.”
Reasonable evidence includes (but is not limited to) “an advertisement; written confirmation from a vendor; or any other reliable form of proof of the retail price.”
Honeypot Consulting looking for great people
Honeypot Consulting is a leading-edge independent medical consulting firm working in the insurance, employer, government and legal sectors. We have a team of specialized medical professionals certified and trained in conducting independent medical evaluations. We are currently looking for great people to grow with us. Please send resumes to info@hopomail.com.
Intact Insurance profit rises to 101 million.
The Toronto-based property and casualty insurance provider had $101 million of net income, or 87 cents per share, in the third quarter.
“Our underwriting performance continued to be strong this quarter as personal auto results improved significantly,” said Charles Brindamour, Intact’s chief executive officer.
FSCO to be fixed by March?
FSCO, an agency of the finance ministry, is adding resources so cases can be mediated in the legislated 60 days by the end of March providing insurance companies and their clients have lawyers ready, said a spokesman for Duncan.
Both insurers and the rehabilitation industry are watching closely, recognizing that the new $3,500 cap on minor injury assessments and claims — the bulk of accidents — depends on how those cases are decided.
“The longer it takes to get these cases through the system, the longer there’s uncertainty and the more difficult it is for insurance companies to budget and price their products appropriately,” says Ralph Palumbo of the Insurance Bureau of Canada.
Do you want to help me fix the MIG?
FSCO is requesting assistance in the development of a program to replace the $3500 monetary cap. I would be interested in joining a team to bid on this RFP.
Scope of Work: This Request for Proposals (“RFP”) is issued by Her Majesty the Queen in right of Ontario as represented by the Ministry of Finance, Financial Services Commission of Ontario (“FSCO”). The RFP is for the provision of Consulting Services for the Development of a Minor Injury Treatment Protocol as more fully described in Part 2 – The Deliverables (the “Deliverables”) of this RFP. These services will assist in fulfilling the government’s direction to replace the interim $3,500 monetary cap for minor injuries with an extensive continuum of care for minor injuries based on current scientific and medical evidence.
Auditor General reviews the workings of FSCO
On December 5th, The Auditor General released the 2011 report. Chapter dealt with Auto Insurance Regulatory Oversight.
PURPOSE: Our audit objective was to assess whether FSCO had adequate systems and procedures in place with respect to its auto insurance responsibilities to:
• ensure compliance with relevant legislation and its own policies established to protect the public interest and to enhance public confidence
in the auto insurance sector;
• administer the Motor Vehicle Accident Claims Fund in the public interest; and
• measure and report on the effectiveness of its regulatory oversight.
Considering that this was an audit I found it surprising that the Auditor General referred to “industry estimates” to report on the level of fraud.
It was interesting to note that there are significant backlogs in FSCO’s mediation services for claimants in dispute with insurers, with resolutions taking 10 to 12 months rather than the legislated 60 days.
Recommendations from the auditor to fix this issue:
1. Improve its information-gathering to help explain why almost half of all injury claimants seek mediation, as well as how disputes are resolved, and to identify possible systemic problems with its SABS benefits policies that can be changed or clarified to help prevent disputes;
Maybe they could start by reading the newspaper or talking to anyone in the industry. Clearly claimants do not feel that $3500 is a reasonable amount of coverage.
• establish an action plan and timetable for reducing its current and growing backlog to a point where it can provide mediation services in a timely manner in accordance with legislation and established service standards.
Maybe they could start by expediting some arbitration cases to provide some guidance on topics of dispute:
1. What kind of and when does medical information need to be provided provided in response to an OCF-18.
2. What is compelling evidence that a claimant will not fully recover within the MIG.
CAT determination in favour of client
Renée Vinett of HSH recently succeeded in an arbitration at FSCO for a determination that her client, Mr. C, sustained a catastrophic impairment under the “mental and behavioural disorder” section of the Statutory Accident Benefits Schedule.
Renee Vinett
Read the full article in the Howie, Sacks & Henry November newsletter.
Do you have your 40 hours of CE credits? June 30th 2012 is the deadline.
Every CCO member holding a general certificate of registration is required to maintain a professional portfolio, which will be made available to the QA Committee upon request or to the peer assessor during a peer assessment.
Members will be required to complete the Continuing Education and Professional Development Log as part of their registration renewal. In this document, members must demonstrate that they have completed their 40 hours of CE over a two-year cycle.
1st Cycle: July 1, 2010 – June 30, 2012
Members will be required to complete their self assessment and CE requirements (i.e., 40 hours) once in each of the above cycles.
The CE log includes courses in the area of assessment and insurance.
Metriks Education offers courses that meet the structured activities section. Take our courses in person, via the internet, or coming soon as a webinar.
New serious injury claims training available for adjusters
The training intends to modify the way an adjuster views the claim and injury, by expanding the perspective to include not just the physical ailment, but what external forces may affect the healing of that ailment.
State Farm is seeking 21 million in damages
An official Statement of Claim was filed November 4, 2011 against Pacific Assessment Centre Inc., Fairview Assessment Centre, M.D. Assessment Consult Inc., Traffic Law Advocate Professional Corporation, Vitali Tourkov, Alexandre Lobatch, Abram Zilber, Danny Grossi, Evgeni Evdassin, Yaniv Tamsout, Alla Lobatch and Dan Sut.
State Farm is claiming $8 million in damages for fraud, fraudulent misrepresentation, and/or unjust enrichment; $8 million in damages for conspiracy; $5 million in aggravated and/or punitive damages; a declaration that State Farm is not required to pay any future or outstanding bills from the defendants; the costs of the action; pre-judgment and post-judgment interest; and HST.
