Anti-Fraud Regulations Come Into Effect June 1

The Ontario Government has made public the regulatory changes that will be made to help combat auto insurance fraud.  The changes were approved on January 21, 2013 and are scheduled to come into effect on June 1, 2013. 

Regulation 14/13 amends the Statutory Accident Benefits Schedule (SABS) - 34/10. 

The amendments to the SABS include:

• a requirement for insurers to provide all reasons when denying medical and rehabilitation claims; 
• providing FSCO with authority to stipulate additional information that insurers must provide in bi-monthly benefit statements to claimants; 
• giving insurers authority to require claimant confirmation of receipt of goods and services that have been billed; and 
• providing FSCO with authority to stipulate by Guideline the maximum payable by insurers for goods as well as services.

Interesting that the government chose to only amend section 38(8) which deals with requiring insurers to give reasons for denying medical and rehabilitation claims.  The same language exists in 12 other sections of the SABS (listed in a previous post) and those sections were not amended.  That would suggest there are now two standards for communicating denials to claimants.  As well the language change from “the medical and any other reasons why the insurer considers any goods, services, assessments and examinations, or the proposed costs of them, not to be reasonable or necessary” to “the medical reasons and all of the other reasons why the insurer considers any goods, services, assessments and examinations, or the proposed costs of them, not to be reasonable and necessary” does appear substantially different.

The Cost of Goods Guideline was issued by FSCO in January 2012.

FSCO also plans to issue a standard form prior the regulation coming into effect that insurers will be required to use for the purposes of the bi-monthly benefit statements to claimants.

Regulation 15/10 amends the Unfair or Deceptive Acts or Practices (UDAP) Regulation - 7/00.

The changes to the UDAP regulation include:

• an offence to request, require or permit a claimant to sign an incomplete claim form and 
• clarifying the exemption for lawyers and paralegals to ensure the regulation applies to lawyers and paralegals when not acting in a legal capacity.

Regulation 16/13 amends the Disputes Between Insurers (DBI) Regulation - 283/95.

The amendment to the DBI regulation allows for the insurer that receives the initial application for benefits to request one examination of the claimant under oath to assist in the determination of priority issues.

This amendment provides insurers with a second opportunity to request a claimant undergo an examination under oath.  The new DBI requirement is to assist an insurer to determine which insurer is liable to pay the claimant accident benefits.  The SABS provisions continues to assist an insurer to determine whether the claimant entitled to accident benefits.