ORA Response to the Consultations on Implementation of the $2 mil CAT benefit

Read PDF Version: ORA Submission re $2 mil CAT

$2 Million Catastrophic Impairment Default Benefit Limit Consultation
Submitted by the Ontario Rehab Alliance
Via email to: [email protected]
September 16, 2019

Contact: Laurie Davis, Executive Director- [email protected]

About the ORA: The ORA represents primarily small to medium sized healthcare businesses that collectively employ upwards of 4000 healthcare providers including Regulated Health Professionals from all disciplines, social workers, personal support and rehabilitation support workers. We are the primary providers of rehabilitation to Ontarians seriously injured in automobile accidents. Most of our members work throughout the healthcare system, giving us a wide-angle view. We are the only association focused primarily on the interests and issues of health providers in the auto sector.

Our member companies operate in home, community and clinic settings. As health professionals we have a strong duty of care to our clients, as business owners we have a responsibility to keep the business viable for ourselves, our staff, and the clients who depend on us.

On behalf of its members, the ORA advocates for motor vehicle accident victims, adequate insurance benefits, and fair treatment of those injured. We help members to navigate the claims system with timely information bulletins on new requirements and issues, and with resources to support daily operations.

Implementation Details and Options
Note: The ORA has focused its response of the consultation questions where we have expertise to contribute. We have responded to the others with ‘no comment’.

4. What potential benefits or implementation challenges should the government consider regarding the proposed approach?

Potential Benefits
It is a certainty that the increase to $2mil will have a tremendously positive impact on those who are catastrophically injured, enabling them to achieve the highest quality of life post-accident. In doing so, it will also lessen the pressure on publicly funded health care (family physicians, emergency rooms) and social services. The higher benefit level will mitigate the
negative impact that such injuries have on spouses and family members, helping to preserve these all-important relationships.

We believe that it is important to recognize that $2 million is necessary, and that the $1 mil limit currently in place has proven woefully inadequate. The costs that CAT claimants incur are not picked up by any other funding mechanism. Examples include home and vehicle modifications, prostheses, and life-long attendant care needs. Each of these costs can be in the range of
hundreds of thousands, so that even the $2 mil benefit level may be consumed. This is exactly the population that the CAT benefit is designed for.

Implementation Challenges
The option to reduce the $2 mil default benefit to $1mil and thereby achieve premium cost reduction presents huge challenges. There are few, if any, alternate sources of insurance for the degree of med-rehab support required to treat catastrophic injuries and the average consumer is generally not well informed about the provisions of any other insurance they might have. They
may well think that their workplace extended health plan includes such coverage when it does not. Similarly, long-term disability benefits are rarely understood and, depending on the plan, may not cover the costs on injuries sustained; nor do they cover the costs of injuries sustained by others in the vehicle.

This ‘buy down’ possibility is deeply worrying for a number of reasons.

Historically, few consumers buy-up accident benefits, and this same phenomena will play out in reverse, with most choosing the cheapest rather than the wisest policy.

Most drivers do not consider it likely that they will be in an accident that leaves someone seriously, let alone catastrophically injured. They don’t know they that they need this coverage, until they do.

Insurance brokers and agents do not themselves understand the cost of serious and catastrophic injuries and are therefore not able to properly dissuade those deciding to “buy down”.

Implementation will need to somehow mitigate all the above in order to ensure that the $2 mil does properly function as ‘default’.

5. What potential implementation costs should government consider regarding the proposed approach? Who will bear those costs? For example:

a) Impacts to average premium for consumers
Without historic data, which can only be supplied by insurers on the cost differential of the $1mil and $2mil, it is not possible to speculate on the implementation costs might be. We can more easily imagine what the impacts of the 2016 benefit reduction have been, and that will continue to play out. Without access to appropriate care, those with catastrophic injuries will be compounding the hallway medicine stresses on our healthcare system and social services.

If implementation can ensure that most people keep the $2 mil default, then the implementation costs of education of all stakeholders is minimized. Eliminating the buydown option will certainly minimize the implementation costs associated with having to educate insurance sellers and consumers.

Further, we believe that there are a number of cost savings that may arise from other auto reform initiatives (fewer IMEs, fewer disputes) that can offset any new costs.

b) Impacts to administrative costs for insurance industry stakeholders
No comment.

c) Other?
No comment.

6. What measures could be considered that would avoid unnecessary disputes and/or litigation costs?

Regardless of the benefit level in place, the current process for determination of CAT designation is problematic and should be reviewed and the issues addressed.

These include:

– Length of time (often 2-3yrs) for CAT determination to be made
– The 30-day vegetative clause should be removed. If someone is vegetative for more than “x” hours (e.g. 24/48) then they should have access to cat benefits.
– Establish a committee to review how the new cat definition is meeting needs.
– Likelihood that those who will be deemed CAT will exhaust the $65,000 med-rehab benefit long before they are awarded CAT level benefits and be without desperately needed treatment and supports during this period.
– It is vital to collect data that will show how often the 65k is exhausted and the injured person is later deemed CAT. Anecdotally, we see a lot of these cases, but policy makers should become aware of the frequency with which this occurs.
– The waiting period between exhausted benefits and CAT determination makes those in that group more difficult to treat as they are not getting the right treatment at the right time. This often contributes to increased mental health sequelae due to increased financial pressures, frustration with lack of improvement, and ongoing assessments to meet CAT criteria, which further complicates the recovery process
– Likelihood that those who will be deemed CAT will exhaust the $65,000 med-rehab benefit long before they are awarded CAT level benefits and be without desperately needed treatment and supports during this period.

7. Should MVACF claims be subject to the $2 million default benefit limit?
Absolutely. Pedestrians, cyclists and the uninsured hurt by uninsured drivers will require the same level of med-rehab support.

8. What additional changes could the government consider to achieve and/or support the stated policy objectives? What are the risks, opportunities, and costs associated with these other approaches?

Reconsider offering the ‘buy down’ option. If implemented, establish measures to ensure insurers are mandated to develop and deliver educational resources for consumers

Implement mechanisms to speed up CAT determination, such as the ability to submit a CAT application when there is a clear med-rehab need to do so as opposed to the arbitrary timelines of 9 months or 1 year. This aligns with the Care, Not Cash approach.

Supporting Implementation: Consumer Choice and Awareness

9. What current practices, materials, and tools are used to help consumers understand auto insurance, including the catastrophic impairment benefit? Which approaches or tools are the most effective and why?

For the most part, the consumers we meet in the course of our work are already seriously or catastrophically injured. Rarely did they have any understanding of the potential for such injuries before they occurred. In our industry, it is the common experience that we, as consumers, have to educate — and almost persuade —- our brokers and insurance agents in
order to buy up the optional benefits we need. When we inquire of family and friends who we have encouraged to also buy-up they report similar experiences. Consequently, we have little faith that there are currently practices, materials and tools in place to help insurers understand
auto insurance and accident benefits. Our association has developed resources to support broker and insurer education which we’d be happy to share more widely. We also provide some general information the public and our clients:

Understanding Auto Insurance

It is vital that insurer and consumer education includes information about the costs incurred. As mentioned previously, this should include home and vehicle modifications, prosthetics, and lifelong attendant care.

10. What should the insurance industry (i.e. insurers, agents, brokers) do, that they aren’t currently doing, to support consumer awareness and informed decision making? What other
opportunities exist to enhance consumer awareness / education?

This is an expensive and uphill battle when CAT represents only 1% of claims and when insurers have an obligation to ensure they are providing consumers with the information they need to make sound decisions. To have any hope of doing so, insurers themselves must be better informed so that they can then inform consumers. Accident benefits and serious and catastrophic injuries are complex matters. In fairness, it may be asking too much of most insurers to do this well. The costs of healthcare are not well understood by most Canadians. OHIP is managed in such a way that most have no idea what their healthcare costs; only in the auto insurance sector are some of these costs visible. Without any context for understanding or
comparing MVA healthcare and rehab costs, insurers and consumers alike will be prone to seeing the real costs as inflated.

Addressing this issue in the MVA sector should come second to addressing it more widely, and helping Ontarians better understand the costs of healthcare through a similar degree of transparency with the costs of OHIP, WSIB, etc.

11. How do (and/or should) sellers of insurance determine what amount of catastrophic impairment benefit limit to recommend to clients?

As indicated above, the $2mil benefit limit should be mandated for all. Otherwise, how would the conversation between a broker and a consumer go, practically? We envision something like this:

Broker: So your premium will be $150/month, but if you want to save $20 per month you can choose to reduce your cat benefits from 2M to 1M.

Consumer: Do you think I will need it? Is it worth the savings? What would you do?

What can the broker possibly say next that is ethical?

Nah, you probably won’t need it – only 1-2% of people are catastrophic.
But if you are, then yes definitely you will likely need the 2M instead of the 1M – for home modifications that can cost 0.5 million, for specialized equipment like prosthetics that can cost 20-30k and need to be replaced every 5 years, for years of treatment to improve and then treatment to maintain your function.

We understand that some Ontario Auto Insurance brokers and agents have been subject to errors and omissions lawsuits from consumers that cite a failure to provide or to advise of necessary coverage. It seems likely that the proposed buy-down option to lower Catastrophic AB will increase their exposure to such suits in future.

12. What do (and/or should) sellers of insurance do when a consumer does not accept the recommended option?
As above

13. What, if any, other insurance products (e.g. long-term disability insurance) could help address gaps in catastrophic impairment coverage?

Please refer to our reply to #4, above. Further, it is always going to be more cost effective for the consumer to add to the auto insurance product then trying to fill gaps with other coverages.

a) Do sellers of insurance recommend and/or sell these other products to consumers?
No comment.

Additional Comments
14. Please share any additional comments or suggestions you may have to inform the proposed$2 million catastrophic impairment default benefit limit.
No comment.

Healthcare Providers Respond to Auto Reform Announcements with Cautious Optimism

Downloadable PDF: Media Release – Heathcare Providers Cautiously Optimistic About Auto Reform

FOR IMMEDIATE RELEASE
April 15, 2019

Healthcare Providers Respond to Auto Reform Announcements with Cautious Optimism

The Ontario Rehab Alliance (ORA), representing healthcare providers in the auto sector, sees much to applaud in the blueprint to improve the province’s auto insurance system presented in the 2019 Budget.

“On behalf of our seriously injured clients we are thrilled with the return to the higher level of coverage for catastrophic injuries and relieved that this government has protected other accident benefits after years of cuts”, says Laurie Davis, Executive Director of the ORA.

The ORA is fully supportive of the blueprint’s plan to reduce the regulatory burden on health providers, improve the Independent Medical Examination process and minimize red tape and other obstacles that delay treatment of serious injuries.

The ORA has been advocating for a number of these reforms in their discussions with government over the past months.

“Consumers need to know that they will get the support and treatment they need when they are injured. The right reforms can replace obstacles to care with proactive treatment, retain appropriate checks and balances and reduce disputes without increasing costs. This blueprint suggests we may be heading in the right direction,” says Ms. Davis.

The ORA is concerned about the announced intention to lower fees paid to healthcare providers treating accident victims. The association represents primarily small to medium sized providers across the province. Many are already struggling to compete for staff in the labour-short healthcare sector, particularly given the hourly rate freeze in effect since 2012 in the auto sector.

The healthcare association is also concerned about unintended consequences of encouraging claimants to be treated within the insurer’s Preferred Provider Network and restricting settlement of the medical-rehabilitation benefit. The ORA is worried that such changes could lead to disproportionate power in the hands of insurers while leaving claimants without recourse or independent oversight to ensure that they are treated fairly.

The association is cautiously optimistic that it can have productive discussions about its concerns and the potentially dire consequences given this government’s Open for Business focus and looks forward to working with government, insurers and other stakeholders on continuing improvements to the auto insurance system.

————————————————————————
Media contact: Laurie Davis at [email protected] , the telephone numbers above in letterhead or directly at (705) 957-4733.

It’s budget day tomorrow and we’re hoping for change

Colm Holmes is president and CEO of Aviva Canada.

“More choice and a greater range of options should be available for consumers when they are buying auto insurance.”

https://www.theglobeandmail.com/business/commentary/article-auto-insurance-regulation-in-ontario-needs-a-dramatic-overhaul/

Good News re: HST & AB

Ontario ministry issues guidance on paying HST on accident benefits

March 27, 2019   by Jason Contant

Ontario ministry issues guidance on paying HST on accident benefits

Needed: therapists, managers, and coordinators in the field of Traumatic Brain Injury in Ontario

Dear Members

I am Sareh Zarshenas, post-doctoral fellow, working under the supervision of Dr. Carolina Bottari at the University of Montreal and with Dr. Deirdre Dawson at the Rotman Research Institute, Baycrest. We are working on the project entitled

smart home technology as a platform to implement cognitive interventions to facilitate safety and independence within the homes of individuals with traumatic brain injury: first steps towards a multi-site trial in Ontario”.

This project is funded by the Canadian Trauma Research Consortium and the ONF-REPAR and has received ethics approval from the REB at Baycrest.

We are looking for experienced occupational therapists, physical therapists, speech language pathologists, psychologists, personal support workers, behavioral therapists, occupational/ physical therapy assistants, managers/coordinators, and funders who have experience working with TBI patients in outpatient rehabilitation facilities as well as community settings to participate in a focus group or a personal interview.

Participants will receive $70

Please find attached below, more information on this project and do not hesitate to share this email with your colleagues.

Invitation letter smart home project

 

Potential participants please contact Sareh Zarshenas at  [email protected] If you have any questions about this project, please contact Dr. Dawson at [email protected]

Thank you so much for your consideration,

 

BSc., MSc., OT Reg. (Ont.), PhD.

Post-Doctoral Fellow,

University of Montreal, Faculty of Medicine

Centre for Interdisciplinary Research

in Rehabilitation of Greater Montreal (CRIR)

Office address: Department of Occupational Science

&Occupational Therapy, University of Toronto,

500 University Ave, Toronto, ON.

Your postal code is a big factor in determining your car insurance rates. Critics say it shouldn’t be- Patty Winsa

Insurance.JPG

NEWS 05:50 AM by Patty Winsa Toronto Star

“When Pankaj Sallh and his family moved to Brampton from Mississauga last year, he had no idea that changing his postal code would be so costly.

The relocation resulted in a nearly 50 per cent increase in his car insurance with the same company, from $237 to $350 a month for two vehicles.

“To me, it’s unexplainable,” says Sallh. The 44-year-old engineer and his wife support two small children, as well as his parents and father-in-law. “Why should I pay more just because of the change of address?”

 

Read the whole article at the link below:

https://www.thespec.com/news-story/9215109-your-postal-code-is-a-big-factor-in-determining-your-car-insurance-rates-critics-say-it-shouldn-t-be/

ORA’s Auto Insurance Reform Submission

Dear members

Below is our just-posted Auto Insurance Reform submission. It certainly was challenging to stick to the 500 word limit when there’s so much to say. However, we do expect to have opportunities to say more in person to policy makers in the coming weeks and months. We also had a very interesting meeting with FSRA’s Board of Directors recently and I’ll share more about that soon.

ORA Auto Insurance Reform Submission PDF

Raise auto accident benefits: Ontario politician

Singh said he plans to “work with stakeholders involved to determine that specific number and find out where we need to go to make sure that every single Ontarian has the protections they need if they get into an accident”  View full article here

October 31, 2018   by Greg Meckbach

Gurratan Singh is the brother of federal NDP leader Jagmeet Singh. He is the current MPP representing Brampton East with a Parliamentary role in critiquing Auto Insurance. Further details to his political career can be found here

 

Accident victims denied millions in benefits by insurers, lawsuits allege- Toronto Star

“Six auto insurance giants have withheld hundreds of millions of dollars in HST payments from Ontario car accident victims in defiance of repeated demands from the provincial regulator, according to a series of class-action lawsuits — obtained exclusively by the Toronto Star — claiming $600 million in damages.”

Follow the link below for full article:

https://www.thestar.com/news/investigations/2018/11/01/accident-victims-denied-millions-in-benefits-by-insurers-lawsuits-allege.html?fbclid=IwAR2zl9Qhy7h0Oeq1YAe2Db_jCVwlsvylE_B22HxjWeL7nM3RBLwWnA7v8Pk

A ‘startling turn of events’: Judge rules case points to improper influence in Ontario auto insurance disputes | National Post

Mary Shuttleworth was the front seat passenger in her friend’s Pontiac Sunfire on a winding Ontario country road early one rainy morning in 2012 when a pickup truck came around a corner, clipped it on the front headlight, and sent it spinning into a ditch, where it landed “with the nose pointed up, looking at the stars.”

The airbags deployed. Her head was pinned between the seat and the door frame, and rescuers had to use the Jaws of Life to get her out. It was her 49th birthday.

Today, nearly six years later, the physical toll of a traumatic brain injury, soft tissue injuries and post-concussive syndrome has left her unable to work, with frequent nausea and vertigo, and fearful of becoming a burden to her family.

But when a newly constituted Ontario government tribunal considered whether her injuries were “catastrophic” — in the first such case to come before it after major reform of the auto insurance industry — the controversial outcome has thrown Ontario’s no-fault car insurance regime into confusion.

Thanks to an anonymous letter mailed to Shuttleworth’s lawyer, Gary Mazin, alleging improper influence in the Licence Appeal Tribunal, a judge has found there is reasonable basis to believe the decision to deny Shuttleworth benefits “did not reflect the independent decision of the adjudicator.”

According to the letter, the adjudicator initially decided to approve Shuttleworth’s benefits, only to have the denial ordered from on high by the adjudicator’s boss.

“Justice must not only be done; it must be seen to be done,” wrote Justice Julie A. Thorburn.

Shuttleworth’s denial of coverage was therefore overturned and sent back for a new hearing. This decision is likely to prompt a flurry of new lawsuits alleging improper influence in the denial of benefits, according to Mazin.

One legal industry commentary called the decision a “startling turn of events.”

The tipster’s letter included information that could only be known to an insider, and it claimed the adjudicator of Shuttleworth’s case, Susan Sapin, originally decided that Shuttleworth’s injuries really were “catastrophic,” which under the law means a 55 per cent impairment of the “whole person,” as judged by a scorecard system.

The letter claimed Sapin’s boss, Linda Lamoureux, executive director of the tribunal’s parent organization, Safety, Licensing Appeals and Standards Ontario, “changed the decision,” and that as a result, Sapin “hesitated to sign this order.”

That led Mazin to file an access to information request for the tribunal’s internal communications about the case and policies on how decisions are made. That request turned up correspondence between Lamoureux and Sapin reflecting a lengthy back-and-forth process of consultation and revision, which was initiated by Lamoureux.

Justice must not only be done; it must be seen to be done

Thorburn found that the process of adjudicating cases like this can fairly involve consultation with colleagues, and that an adjudicator’s boss commenting on a decision does not necessarily prove that there was improper influence. But, in this case, the adjudicator appears to have learned of the executive director’s review of the case after it happened, and without asking for it.

“I make no finding of any actual impropriety having occurred on the facts of this case,” Thorburn wrote. There was no proof that Lamoureux “did anything to force” Sapin to change her decision. But the process by which it was decided “did not meet the minimum standards required to ensure both the existence and the appearance of adjudicative independence of the adjudicator’s decision.”

Unless the consultation process is voluntary and clearly limited to advice, as opposed to control, there will always be a “reasonable basis to believe that the decision did not reflect the independent decision of the adjudicator,” the judge found.

In an interview Monday, Shuttleworth said she has already begun the evaluation process again.

Since 1990, Ontario has had no-fault insurance, which took these disputes out of the civil courts and means that every car insurance policy in the province offers benefits regardless of who was at fault.

Until 2016, these kinds of disputes between insured people and insurance companies were heard by a different tribunal of the Financial Services Commission of Ontario.

As the first case about catastrophic injuries under the new LAT tribunal, Mazin said there was likely concern about the kind of message the decision might send about whether the tribunal is sympathetic to claimants or insurance companies.

• Email: [email protected] | Twitter: