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Report on the Three Year Review of Automobile Insurance, 2014 Page 1 - PDF
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1 Report on the Three Year Review of Automobile Insurance, 2014 Page 1
2 Table of Contents Table of Contents... 2 Executive Summary... 4 Introduction How Insurance Markets Work Key Principles of Insurance Contracts Ontario s Auto Insurance System No-fault and Tort Compensation Incentives in Auto Insurance Systems Snapshot of Participants in Ontario s Auto Insurance System Evolution and Recent History of Auto Insurance in Ontario Cost Reform Cycles Reforms Recent Premium Trends Recent Government Actions Ontario Automobile Insurance Anti-Fraud Task Force Cost and Rate Reduction Strategy Other Long-term Initiatives Ontario s Experience Compared to Other Jurisdictions System Comparison to Provinces with Privately-Delivered Auto Insurance Experience in the UK and Select US Jurisdictions Claims Costs Comparison to Provinces with Privately-Delivered Auto Insurance Accident Benefits Accident Benefit Claims Experience for Private Passenger Vehicles Comparison to Other Provinces with Privately-Delivered Auto Insurance Key Accident Benefits Duration of Medical and Rehabilitation Benefits Eligibility Test for Other Goods and Services Treatment Planning and Approval Experience with the Minor Injury Guideline Education of System Participants around Treatment and Recovery Assessments and Insurer Examinations...35 Report on the Three Year Review of Automobile Insurance, 2014 Page 2
3 7.0 Bodily Injury (Tort) Bodily Injury Claims Experience for Private Passenger Vehicles Comparison to Other Provinces with Privately-Delivered Auto Insurance Rate Approval and Risk Classification Risk Classification System Changes Initiatives and Innovations Following 2010 Reforms Usage Based Automobile Insurance Cost and Rate Reduction Strategy Increased Transparency and Exchange of Information Prescribed Coverages Rate Approval and Risk Classification Issues Identified in Three Year Review Submissions Risk Classification and Territorial Rating Prior Approval of Rates and Risk Classification Systems Summary of Rate Approval and Risk Classification Stakeholder Feedback Other Issues Identified in Three Year Review Submissions Use of Electronic Documents Taxis and Rental Vehicles List of Recommendations...56 Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Report on the Three Year Review of Automobile Insurance, 2014 Page 3
4 Executive Summary In 2013, the Ontario government consolidated three separate automobile insurance related statutory reviews into a single review to be conducted at least every three years under Section 289 of the Insurance Act. The previous three reviews were: A five-year review of Part VI of the Insurance Act (Automobile Insurance) and related regulations; A three-year review of the operation of regulations prescribing or prohibiting coverages and categories of auto insurance, and regulations governing prescribed or prohibited risk classification systems or elements of risk classification systems; and, A two-year review of the Statutory Accidents Benefits Schedule (SABS). This is the first consolidated review. As part of this review, the Financial Services Commission of Ontario (FSCO) invited stakeholders to provide comments and suggestions on how to ensure a stable, sustainable and competitive auto insurance system. From December 17, 2013 to March 31, 2014, FSCO received 63 submissions from stakeholders including consumers, insurance industry representatives, health care providers and organizations, legal representatives or associations, and other interested parties. Their feedback has been incorporated throughout the report and summarized in Sections 9 and 10. Sections 1 to 3 provide an overview and history of Ontario s auto insurance system, including claims cost and premium trends, as well as recent actions taken by government. Sections 4 to 7 examine current claims cost pressures and provide comparisons with other jurisdictions, particularly other Canadian provinces with privately-delivered auto insurance. Section 8 reviews rate approvals and risk classification, including regulations that prescribe or prohibit elements of insurer rating and risk classification. As noted above, Section 9 provides a brief summary of stakeholder feedback and Section 10 addresses a number of other issues identified in stakeholder submissions. Recommendations are incorporated throughout the report and listed in Section 11. Government actions Rising claims costs place upward pressure on premiums. The government has taken critical steps to improve auto insurance affordability in Ontario, including the 2010 auto insurance reforms which successfully stabilized auto insurance claims costs. Recent government actions since the 2010 reforms include: Taking action on over half the recommendations made by the Ontario Auto Insurance Anti-Fraud Task Force to enhance the role of each participant in the Report on the Three Year Review of Automobile Insurance, 2014 Page 4
5 auto insurance sector, including insurers, health care and legal professionals, consumers, FSCO, and the government; Launching the Cost and Rate Reduction Strategy to build on previous anti-fraud efforts and system reforms by: o Licensing health care providers who bill auto insurers directly; o Reviewing and transforming Ontario s auto insurance dispute resolution system to reduce costs and speed up access to accident benefits for injured drivers; and, o Implementing numerous other legislative and regulatory changes to lower costs and protect consumers. In addition, continuing work on long-term initiatives such as the Minor Injury Treatment Protocol aimed at developing evidence-based approaches for the treatment of injuries. Current system, rate and cost trends Reviews conducted by the Ontario Auto Insurance Anti-Fraud Task Force and by Justice Cunningham on the Dispute Resolution System demonstrate that all auto insurance system participants and the stakeholder culture can contribute to a sustainable and well-functioning auto insurance system. Approved rates, which are an indicator of future premium trends, started declining in 2012 and Average premiums also started trending downward in the 2013 accident year, compared to Despite recent successes in tackling overutilization and fraud, Ontario continues to have the highest claims costs among Canadian provinces with privatelydelivered auto insurance. Ontario s average claims cost per private passenger vehicle was about $1,000 over the 2011 to 2013 accident year period 1 - which ranges from approximately 20% higher to over twice the costs in comparable provinces. High auto insurance claims costs in Ontario are linked to: o Average accident benefits claims costs per private passenger vehicle of $305 over the 2011 to 2013 accident year period, which ranges from about 5 to 10 times the costs in comparable provinces; and, o Average bodily injury (tort) claims costs per private passenger vehicle are among the highest, at $363 in the 2013 accident year. Ontario has the most generous package of mandatory accident benefits among Canadian provinces with privately-delivered auto insurance. 1 An accident year is the year when the accident occurred, regardless of when the claim was reported to the insurance company or when claim payments are actually made. E.g. an accident may have occurred in 2011 but claim payments are made in 2012 and Those claim payments would still be attributed to the 2011 accident year. Report on the Three Year Review of Automobile Insurance, 2014 Page 5
6 Increases in the cost and frequency of bodily injury (tort) claims are now creating more pressure on the overall cost of the auto insurance system. Looking forward This new statutory three year review on auto insurance will help maintain focus on the rapidly evolving auto insurance landscape and help ensure that auto insurance remains available and affordable for over 9 million Ontario drivers. This report highlights areas where the government could consider making additional reforms to further contain claims costs, increase consumer choice, and achieve other system improvements. This report also identifies areas where participants in the auto insurance system can take leadership and contribute to the affordability and appropriate functioning of the system. Report on the Three Year Review of Automobile Insurance, 2014 Page 6
7 Introduction In 2013, the Ontario government consolidated three separate automobile insurance related statutory reviews into a single review to be conducted at least every three years under Section 289 of the Insurance Act (Act). This is the first such review. Section 289 of the Act requires the Superintendent of Financial Services (Superintendent) at the Financial Services Commission of Ontario (FSCO) to undertake a review at least every three years of Part VI of the Act (Automobile Insurance) and related regulations as well as regulations involving auto insurance coverages and risk classification systems. The Superintendent is to give a report to the Minister of Finance setting out the results of the review, any recommendations made by the Superintendent and such other information as the Minister may request. See Appendix 1 for further details. This report fulfills the requirements under Section 289 of the Act. 1 How Insurance Markets Work Insurance is a financial contract between an insurer and an insured it provides economic protection for the insured against specified losses in exchange for the payment of premiums. Insurance is a promise to pay and formalizes the transfer of risk from the insured to the insurer over a defined period of time. Auto insurance is a type of property and casualty (P&C) insurance that provides compensation for events such as vehicle damage, personal injury, and liability for damages and injuries caused to others. Since 1980, auto insurance has been mandatory in Ontario. All vehicle owners, whether a resident, a business, or a public institution, are required to purchase auto insurance before operating a vehicle on a public road. Insurance is based on the pooling of risk. In other words, the losses of few are paid for by the premiums of many. In Ontario, auto insurance is a closed loop system where all costs (including claim and claim adjustment costs, operating expenses, taxes and assessments) are recovered through premiums and investment income on those premiums. If costs go up, premiums will follow. Over the 2009 to 2013 accident year time period, claim and claim adjustment costs for private passenger automobile insurance in Ontario accounted for 75% of premiums. 2 If insurers cannot recoup their costs, the availability of insurance will suffer. The longterm financial sustainability of insurers helps to ensure that auto insurance is available General Insurance Statistical Agency exhibit for private passenger vehicles. Accident Year data is subject to change as claims are paid and more information becomes available on the ultimate settlement costs of claims. It can take many years for the extent and costs of injuries to be fully measured. Report on the Three Year Review of Automobile Insurance, 2014 Page 7
8 to vehicle owners and drivers and that there are sufficient funds to provide compensation for claimants. Chart 1 illustrates the concept of pooling. It shows that about 1% of insured private passenger vehicles have had claims under their accident benefit coverage (coverage for treatment of injuries and certain economic losses) over the last five accident years. Appendix 2 provides more details on claim rates for key auto insurance coverages. Chart 1 Accident Benefit Claims compared to Insured Private Passenger Vehicles Annual Average 2009 to 2013 accident years Accident benefit claims 1% 99% Insured vehicles without an accident benefit claim Source: 2013 General Insurance Statistical Agency exhibit for private passenger vehicles. 1.1 Key Principles of Insurance Contracts Several key principles applicable to insurance contracts are designed to ensure the financial sustainability of insurance markets, protect insureds from unnecessarily high premiums, and establish the roles and responsibilities of insurers and insureds. These principles are described below: Utmost good faith: insurance works on mutual trust and calls for the highest standards of integrity for both the insured and insurer. For example, both parties must fully and voluntarily reveal all relevant information that could influence the other party s decision to enter into an insurance contract, and they must not provide misleading information. It also means that both parties are responsible for fair dealing with each other at all times. Indemnity: insurance generally aims to restore an insured to their pre-loss financial state. Insurance is not intended as a source of financial gain or profit for a claimant; rather, it is intended to make the insured whole again. Although there may be practical limitations with accurately quantifying losses, the principle of indemnity is an important one. If unfortunate events resulted in gain, this could Report on the Three Year Review of Automobile Insurance, 2014 Page 8
9 lead to engineering or exaggeration of losses and result in higher costs for others who pay premiums. Loss minimization: in addition to not seeking to profit from insurance, an insured should take reasonable steps to prevent and reduce losses as these losses will also be in part or in whole borne by others. Fair compensation: insurance is a form of consumer protection. It is intended to restore the financial state of a person who has experienced a loss. Insurers have a duty to address eligible claims fairly in accordance with the insurance contract and any other legal requirements. At the same time, insurers have a duty to avoid servicing claims that are frivolous, excessive or ineligible. 2 Ontario s Auto Insurance System The requirement for vehicle owners to have auto insurance has led to increased oversight and regulation of Ontario s auto insurance system. Key public policy objectives include consumer protection, insurance availability and affordability, consumer fairness and choice, and adequacy and timeliness of compensation. This framework also takes into account insurer financial sustainability in the context of rate and risk classification approvals. Ontario s regulatory scheme for auto insurance establishes: The role of liability in determining compensation how responsibility for causing a collision affects eligibility for insurance coverage (see Section 2.1); The required elements of the auto insurance contract mandatory and optional coverages including statutory accident benefits, third-party liability, and other coverages; The delivery of auto insurance all auto insurance coverages are offered by private companies; and, The regulatory framework which governs how insurers determine rates and the requirement for rates to be approved prior to use in the marketplace (see Section 8). Ontario s auto insurance system includes both mandatory and optional coverages and benefits. The minimum auto insurance contract required by law includes: Statutory accident benefits coverage for treatment of injuries and certain economic losses resulting from injuries, as well as death and funeral benefits (established in the SABS); Third-party liability coverages for injury or vehicle damage caused to others; Direct compensation coverage for damage to the insured vehicle caused by another driver; and, Report on the Three Year Review of Automobile Insurance, 2014 Page 9
10 Uninsured automobile protection: coverage for injury caused by an uninsured or unidentified automobile, and vehicle damage caused by an identified, uninsured motorist. Most consumers also purchase optional underinsured motorist coverage. As well, many consumers, particularly those with newer vehicles, purchase optional loss or damage coverages such as collision or upset, comprehensive, specified perils, and all perils. Appendix 3 provides more details on mandatory and optional auto insurance coverages in Ontario. 2.1 No-fault and Tort Compensation A fundamental element of any auto insurance system is the degree to which liability or fault for a collision affects how a person experiencing injury or property damage may seek compensation. No-fault coverages compensate an insured person regardless of their role in causing a collision. In exchange for this guaranteed coverage, no-fault systems generally place some or total restrictions on the ability to sue an at-fault driver for injuries or damages. No-fault systems are intended to achieve quicker and more broadly accessible compensation and treatment, as well as lower settlement and legal transaction costs (by reducing liability claims). In a fault or tort system, the insurer of a driver who caused a collision pays for injuries and damages to third parties. Not-at-fault claimants seek compensation via court-based awards. The at-fault driver may receive limited to no compensation under mandatory auto insurance coverages. Many regulatory regimes seek a balance between no-fault coverages and tort access by combining no-fault accident benefits with the right to sue at-fault parties. In Ontario, access to a more comprehensive set of accident benefits is offset by greater restrictions on the right to sue for pain and suffering and excess health care expenses. In Alberta, Nova Scotia, and other provinces with privately-delivered auto insurance, there are fewer restrictions on the right to sue combined with lower accident benefits coverage. Alternatively, some jurisdictions, such as Saskatchewan, provide a choice between purchasing tort or no-fault based auto insurance. 2.2 Incentives in Auto Insurance Systems In general, no-fault systems exchange liability costs in the tort system with no-fault accident benefit costs. The overall effect of no-fault compensation on auto insurance costs depends, in part, on the specific features of the system (e.g., generosity of nofault benefits, strength of tort restrictions) and how system participants respond to incentives. Incentives and participant behaviours can erode or support the basic principles of utmost good faith, indemnity, loss minimization and fair compensation. Report on the Three Year Review of Automobile Insurance, 2014 Page 10
11 For example, unrestricted access to tort may result in extensive delays in receiving compensation, more court actions and overall higher legal costs in the system. Overly generous no-fault accident benefits may encourage overuse and overbilling as providers and recipients have little motivation to minimize costs. There are risks of higher costs in both systems. 2.3 Snapshot of Participants in Ontario s Auto Insurance System Figure 1. Major Participants and Interactions in the Ontario Auto Insurance System* Drivers 9.4 million drivers 1 Auto Insurance 118 auto insurers 18,212 general insurance brokers 8 Injuries 62,019 persons injured 1 Private Passenger Policies and Claims 6.9 million insured vehicles 2 67,541 accident benefit claims 2 Legal Services 2,786 paralegals and lawyers 3 Disputes and Tort 22,794 mediation applications 4 7,958 arbitration applications 4 13,789 bodily injury claims 5 Assessment and Treatment 59,080 claimants 6 55,375 claimants treated and 52,193 claimants assessed 6 Health Care 30,800+ private providers 7 9,300+ facilities 7 1 Ontario Road Safety Annual Report 2011, Ministry of Transportation accident year, 2013 General Insurance Statistical Agency exhibit for private passenger vehicles FSCO Dispute Resolution System (DRS) data accident year data from FSCO DRS group accident year, 2013 General Insurance Statistical Agency exhibit for private passenger vehicles accident year data from Ontario Health Claims Database (HCDB), August 2014 report annual average based on business information reported to Health Claims for Auto Insurance (HCAI). 8 Registered Insurance Brokers of Ontario, as of August Number not specific to auto insurance. *Due to data limitations, Figure 1 does not fully capture all participants and their interactions. For instance, towing, storage and vehicle repair businesses and their services are not represented, information around the number of health care providers and legal representatives and their services is limited, and the cited General Insurance Statistical Agency data represents only transactions related to private passenger vehicles. Report on the Three Year Review of Automobile Insurance, 2014 Page 11
12 A large number of individuals and businesses are involved in Ontario s auto insurance system, including: Suppliers of insurance (insurers); Distributors of insurance (brokers and agents); Consumers, some of whom are claimants; and, Those providing services to a claimant and/or an insurer, such as: o Health care goods and service providers; o Legal representatives; o Towing operators, auto storage and repair shops; and, o Providers of other goods or services that may be covered under an insurance contract (e.g., home and vehicle modifications). Figure 1 is a snapshot of available information about the major participants in Ontario s auto insurance system. Number of Drivers and Vehicles There are currently over 9 million drivers and 6.9 million insured private passenger vehicles in Ontario. In 2013, the Ontario market for all insured vehicles accounted for $12.6 billion in written premiums about 28% of all P&C written premiums in Canada. 3 Auto insurance for private passenger vehicles accounts for over 86% of all written auto insurance premiums in Ontario. 4 Number of Insurers There are currently 118 companies that write auto insurance in Ontario. 5 Of these, about 92 insurers write under the private passenger auto insurance category. 6 This is a decrease from the 101 companies that offered private passenger auto insurance in In 2013, the 20 largest insurance companies wrote 82% of premiums for private passenger vehicles. Little has changed since 2010 when the 20 largest companies wrote 80% of premiums for private passenger vehicles. Although there appears to be a trend toward consolidation among auto insurers it is having little impact on the amount of premiums written. 3 Source: Canadian Underwriter, 2014 Statistical Issue. 4 Sources: Canadian Underwriter, 2014 Statistical Issue; 2013 General Insurance Statistical Agency exhibit for private passenger vehicles. 5 Office of the Superintendent of Financial Institutions (OSFI) and FSCO. 6 FSCO estimate based on General Insurance Statistical Agency market share data. 7 FSCO estimate based on General Insurance Statistical Agency market share data. Report on the Three Year Review of Automobile Insurance, 2014 Page 12
13 There is also an increasing trend toward Canadian ownership among national property and casualty (P&C) insurers from 45% in 1999 to an expected 67% in Evolution and Recent History of Auto Insurance in Ontario 3.1 Cost Reform Cycles Ontario s complex auto insurance system has undergone a number of significant reforms over the past 25 years. Each set of changes resulted in some initial success in stabilizing costs and premiums followed by another cycle of rising costs. Appendix 4 is a summary of the evolution of Ontario s auto insurance system since 1980, when auto insurance became mandatory. Over the years, rising costs in Ontario s auto insurance system prompted governments to reform the system. Changes were made in 1990, 1996, 2003 and 2010 in an effort to re-establish an appropriate balance between rates and coverages, and between the compensation available in the tort system (the right to sue) and the no-fault accident benefits structure. In addition, the compensation framework was revised in Chart 2 illustrates this cycle and shows how costs and premiums have responded to the 1990, 1996, 2003 and 2010 reforms. $1,600 $1, Reforms $1, Reforms $1,000 $800 $600 $400 $200 $0 Chart 2 Auto Insurance Premiums and Claims Costs Reacting to Major Cost Control Measures (1990 to 2013) 2010 Reforms 2003 Reforms Average premium per vehicle Average claims costs per vehicle Source: General Insurance Statistical Agency exhibits for private passenger vehicles. 8 The Changing Face of the Canadian P&C Insurance Industry, by Graham Segger and Joel Baker. MSA Quarterly Outlook Report, Q1-2014, June 2014, pg. 7 to 9. Estimates based on direct written premiums for all lines. Report on the Three Year Review of Automobile Insurance, 2014 Page 13
14 Reforms In Ontario, accident benefits, bodily injury (tort), direct compensation property damage, and collision coverages are typically the largest components of private passenger auto insurance claims costs, as shown in Chart 3. The chart also illustrates how total claims costs for private passenger vehicles have reflected the cost reform cycles. These have changed from $5.0 billion in the 2004 accident year and $8.3 billion in the 2010 accident year, to $7.3 billion in the 2013 accident year. Chart 3 Source: General Insurance Statistical Agency exhibits for private passenger vehicles. Prior to the 2010 reforms, auto insurance claims costs for private passenger vehicles were rising dramatically peaking at $8.3 billion in the 2010 accident year. This was largely due to accident benefits costs which increased from $1.6 billion in the 2004 accident year to $3.8 billion in the 2010 accident year. 9 Decrease in Reported Injuries It would be reasonable to expect that the number of reported injured persons and injury claims would parallel one another. However, that has not been the case in Ontario. Between 2004 and 2010, the number of reported injured persons fell, while the number of accident benefits claims grew significantly. Chart 4 illustrates the overall trend of declining numbers of injured persons and increasing accident benefit claims since General Insurance Statistical Agency exhibits for private passenger vehicles. Report on the Three Year Review of Automobile Insurance, 2014 Page 14
15 Chart 4 Injured Persons and Accident Benefits Claims 2004 to 2013 (accident years) 100,000 Injured Persons (reported) No. of AB claims for personal passenger vehicles 80,000 60,000 40,000 20, Sources: General Insurance Statistical Agency exhibits for private passenger vehicles; Ministry of Transportation (MTO) Ontario Road Safety Annual Reports (ORSAR) 2004 to Road safety data is not available beyond Overutilization and Fraud The Superintendent s 2009 Report on the Five Year Review of Auto Insurance identified the principal factor contributing to pre-2009 increases in claims costs as an overutilization of accident benefits in the system, including over-assessing and over-treating patients, rather than a rise in the number of motor vehicle accidents or injuries. The government s 2010 reforms tackled rising claims costs by introducing new cost controls, making more coverage options available to consumers and focusing on evidence-based approaches to treatment of minor injuries. Appendix 5 provides more information on key accident benefit and tort changes in Insurance fraud was likely an additional factor contributing to the dramatic increase in claims costs prior to In July 2011, the government appointed the Ontario Automobile Insurance Anti-Fraud Task Force (AFTF) to assess the extent and nature of fraud in Ontario s auto insurance system and to recommend actions to reduce fraud. The AFTF concluded that exaggeration of accident benefit claims, unwarranted billing by participants in the system (e.g., overcharging and billing for goods and services not provided), staged accidents and other forms of fraud played a significant role in unexplained cost increases of $2 billion or approximately $300 per registered Report on the Three Year Review of Automobile Insurance, 2014 Page 15
16 passenger vehicle, from 2006 to 2010 accident years. 10 The AFTF also noted that the most dramatic growth occurred in accident benefits, where medical benefit costs more than doubled (105% growth) and examination and assessment costs nearly quadrupled (288% growth). 11 In addition to recommending government and FSCO actions, the AFTF called on all system participants insurers, consumers, claimants, health care providers, lawyers and paralegals, and auto towing, storage and repair businesses to help fight auto insurance fraud. Impact of 2010 Reforms Although claims costs for private passenger vehicles decreased significantly after the September 2010 reforms (see Chart 2), they rose again by approximately 12% from the 2012 accident year to the 2013 accident year. This increase may be due to several factors including potential erosion of cost control measures, insurers increasing their reserves in reaction to uncertainty around future claim costs, and severe winter weather in late It should be noted that claims data is subject to change as more information about the ultimate cost of claims becomes available. It can take many years for the extent and costs of injuries and treatment to be known and fully measured. 3.3 Recent Premium Trends Average written premium increases slowed after the 2010 reforms and have started to move downward in the 2013 accident year as shown in Table 1. Another indicator of rate movement is the average rate change approved by FSCO, which helps predict the future direction of average premiums. Rate approvals have been trending downward since There is always a lag between rate approvals and actual premiums in the marketplace, because an approved rate change does not impact consumers until they renew their insurance policies. 10 Ontario Automobile Insurance Anti-Fraud Task Force, Final Report of the Steering Committee, Ontario Auto Insurance Anti-Fraud Task Force, Interim Report, General Insurance Statistical Agency exhibit for private passenger vehicles shows that the number of physical damage claims for certain coverages increased in 2013 accident year by 7% for direct compensation (not at-fault vehicle damage) and by 9% for collision (optional coverage for a driver s at-fault vehicle repairs). Report on the Three Year Review of Automobile Insurance, 2014 Page 16
17 Table 1 Average Premiums and Rate Approvals for Private Passenger Vehicles Average Written Premium (per vehicle) Average Rate Approval by FSCO 2009 $1, % 2010 $1, % 2011 $1, % 2012 $1, % 2013 $1, % % - (January to September) Sources: 2013 General Insurance Statistical Agency exhibit for private passenger vehicles (accident year basis), and FSCO (calendar year basis). 3.4 Recent Government Actions The September 2010 automobile insurance reforms reduced claims costs and gave drivers more choice and flexibility in choosing levels of coverage. In an effort to avoid a repeat of past reform cost cycles, the government has continued to focus on improving the product in Ontario and deal with the ongoing challenges associated with fraud and misuse of the system; which, if left unchecked, will inevitably contribute to rising premiums as has been seen in the past. The 2010 reforms also included a number of longer-term initiatives, and further actions were announced in the 2011, 2012 and 2013 Ontario Budgets. Initiatives that have been introduced by the government and FSCO after September 1, 2010 are described below Ontario Automobile Insurance Anti-Fraud Task Force In November 2012, the AFTF issued a final report with 38 targeted recommendations. The recommendations formed an integrated anti-fraud strategy by enhancing the role of each participant in the auto insurance sector, including insurers, health care and legal professionals, consumers, FSCO, and the government. To date, the government has taken action to address more than half of the AFTF s recommendations. These include: a) Requiring insurers to provide all reasons when denying claims; b) Requiring insurers to issue additional information to claimants on invoices and expenditures paid out on their behalf in bi-monthly benefit statements; c) Working with health care providers to use the Health Claims for Auto Insurance database to flag clinics that are misusing their credentials and cut down on identity theft; d) Giving insurers authority to require claimant confirmation of receipt of goods and services that have been billed; e) Providing the Superintendent with authority to stipulate by Guideline the maximum payable by insurers for goods as well as services; Report on the Three Year Review of Automobile Insurance, 2014 Page 17
18 f) Making it an offence to request, require or permit a claimant to sign an incomplete claim form; g) Allowing insurers that receive an initial application for benefits to request one examination per claimant, under oath, to assist in determining priority issues; h) Creating an online and phone tip reporting system for suspected auto insurance fraud; i) Consolidating three statutory auto insurance reviews into one 3 Year Review of the auto insurance system; j) Giving the Superintendent the power to impose administrative monetary penalties for contraventions of insurance legislation and regulations; and, k) Licensing the billing and business practices of health care providers and facilities paid directly by auto insurers (described below). A number of the AFTF s recommendations were also implemented through the 2013 Cost and Rate Reduction Strategy outlined below Cost and Rate Reduction Strategy The 2013 Ontario Budget introduced a Cost and Rate Reduction Strategy to build on previous anti-fraud efforts and system reforms that successfully stabilized auto insurance rates in Ontario. In August 2013, this strategy targeted a 15% average rate reduction by August As part the Cost and Rate Reduction Strategy, FSCO conducted an analysis of the change in average rates from August 2013 to August 2014 which showed that average rates declined by 6.03%. The analysis was conducted in accordance with the methodology set out in Ontario Regulation 237/13. Cost and Rate Reduction Strategy Launch The launch of the Cost and Rate Reduction Strategy included legislation that: Expanded and modernized the Superintendent s investigation and enforcement powers; Restored the Superintendent s authority to require insurers to file for new rates; and, Clarified that Superintendent Guidelines, incorporated by reference in the SABS, are binding. The restored rate filing authority was used in 2013 and 2014 to require insurers to file for new private passenger auto insurance rates. As part of the Cost and Rate Reduction Strategy announcement, the government also created a transparency and accountability mechanism in the form of an independent annual report on the impact of auto insurance reforms introduced, current costs and pressures in the system and recommendations on further actions that may be needed to Report on the Three Year Review of Automobile Insurance, 2014 Page 18
19 meet the government s rate reduction targets. KPMG was selected to prepare the report. KPMG completed an interim report which was released by the Ministry of Finance on April 15, KPMG s first annual report was posted on the Ministry of Finance s website on December 11, A second annual report is expected in fall Licensing of Health Care Providers Billing Auto Insurers As a measure to reduce fraud and abuse in the auto insurance system, the AFTF recommended that the Superintendent be given the authority to regulate and licence the business and billing practices of the health service providers (clinics) that are paid directly by auto insurers. The 2013 Ontario Budget provided the Superintendent with this authority and FSCO began accepting licensing applications on June 1, The licensing and oversight process became fully operational on December 1, Now, all health care clinics and assessors that want to be paid directly by auto insurers for specified expenses require a licence from FSCO. Review and Transformation of the Dispute Resolution System FSCO s Dispute Resolution System (DRS) was established in 1990 to provide a timely and cost-effective alternative to the courts to resolve disputes in respect of accident benefits. There have been no significant changes to the DRS since its creation in The demand for DRS services has grown significantly since inception. Additionally, although the DRS was originally envisaged as a system that would help resolve disputes between insurers and claimants without the need for legal representation, there has been a shift toward greater legal representation of claimants with accident benefit disputes. This may reflect a number of factors, including complexity of the auto insurance product, insurer claims adjustment practices, fractious insurer-claimant-legal relationships, and claimant expectations. 13 Appendix 6 provides more details. In August 2013 the Minister of Finance appointed the Honourable J. Douglas Cunningham, former Associate Chief Justice of the Ontario Superior Court of Justice, to conduct a review of the DRS system. Justice Cunningham delivered an interim report in November 2013 and a final report in February The DRS review made a number of observations, including: A high demand for DRS services, particularly in the Greater Toronto Area (GTA); Treatments were the most commonly disputed issue; and, The claims process and the DRS having become adversarial (contrary to the original intent of the DRS) Ontario Automobile Insurance Dispute Resolution Review, Interim Report, Ontario Automobile Insurance Dispute Resolution System Review, Final Report, 2014 Report on the Three Year Review of Automobile Insurance, 2014 Page 19
20 The DRS review also commented on: The culture of the DRS, including the potential impact of claims management practices by some insurers (high case loads and lack of adjuster training) on decision-making and the DRS; and, The focus on cash settlements instead of appropriate treatment which was linked to the leveraging of the DRS cost structure (insurers pay for all mediation and the bulk of arbitration fees) and insurer preference for cost certainty and claim settlement on a full and final basis. 15 The DRS review recommended that the system be reformed based on the principles that cost structures should discourage abuse of the system while protecting accessibility for claimants, and that a positive culture among stakeholders and early resolution of disputes should be encouraged. The final report proposed a transformation of the dispute resolution process that would expedite the resolution of disputes through a new streamlined framework and operate through an independent adjudicative tribunal. The recommendations were intended to reduce costs, and most importantly, speed up access to accident benefits for those who are legitimately entitled to benefits. In November 2014 the government passed the Fighting Fraud and Reducing Automobile Insurance Rates Act, This Act sets out a framework to transform the dispute resolution system based on the recommendations set out in Justice Cunningham s report. February 2014 Regulation Changes The government continued its focus on fraud and consumer protection by introducing additional regulation changes effective February 1, 2014 that: Required that a pre-existing condition that may prevent a person from being treated within the minor injury guideline (MIG) must be documented prior to an accident; Clarified that once an election is made for income replacement, non-earner or caregiver benefits, the election is final, except if a claimant is subsequently determined to have a sustained a catastrophic impairment; and, Established that friends and family members providing attendant care services are to be compensated for their actual economic loss. Fighting Fraud and Reducing Automobile Insurance Rates Act, 2014 In addition to legislative changes to transform the dispute resolution framework (discussed earlier), the Fighting Fraud and Reducing Automobile Insurance Rates Act, 2014, sets out a series of additional reforms aimed at lowering costs in the automobile insurance system and strengthening consumer protection. These include: 15 Ontario Automobile Insurance Dispute Resolution System Review, Interim Report, 2013 Report on the Three Year Review of Automobile Insurance, 2014 Page 20
21 Giving the province authority to change the current 60-day period that a vehicle can be stored after an accident without notice to the owner, where required; Including tow trucks in the province s existing Commercial Vehicle Operator s Registration System; and, Changing the pre-judgement interest rate for pain and suffering awards to current market conditions of 1.3% per annum from the current level of 5% per annum. Overdue payments In November 2014, the government amended the SABS provisions regarding interest on overdue SABS payments. Effective January 1, 2015, in cases where there is a dispute in respect of a person s entitlement to or amount of statutory accident benefits, interest on overdue payments will be based on the same pre-judgment interest rate used in the courts for past pecuniary losses, which is currently set at 1.3% annually. This interest rate applies from the date on which a mediation proceeding is commenced and ends on the date a settlement is reached or decision is issued on the dispute. In situations where accident benefit payments are overdue and there is no dispute, the interest rate of 1% per month compounded monthly will continue to apply Other Long-term Initiatives Development of the Minor Injury Treatment Protocol One of the longer-term initiatives included in the September 2010 reforms was to undertake an evidence-based review of the treatment of minor automobile accident injuries. This review is being overseen by a team of scientists and medical experts. The team was also tasked with developing an evidence-based Minor Injury Treatment Protocol (MITP) for a broad spectrum of minor injuries. A final report is expected by the end of Consultation with stakeholders on the report s recommendations will take place following the completion of the MITP project. Definition of Catastrophic Impairment In 2010, the government directed FSCO to strike a panel of medical experts to examine the definition of catastrophic impairment set out in the SABS, and to set out qualifications and experience requirements for health professionals who conduct catastrophic impairment (CAT) assessments. In December of 2010 an expert panel of clinicians and academics, chaired by Dr. Pierre Côté, was established to review and make recommendations to the Superintendent. The Expert Panel submitted two reports: the first in April 2011, which recommended changes to the definition of catastrophic impairment; and, the second in June 2011 which made recommendations on the training, qualifications and experience of assessors who conduct catastrophic impairment assessments. Report on the Three Year Review of Automobile Insurance, 2014 Page 21
22 Both reports were posted on FSCO s website. Following consultations on the reports, the Superintendent submitted a report and recommendations to the Minister of Finance. The Ministry of Finance released the Report of the Superintendent on the Definition of Catastrophic Impairment and conducted a public consultation in July The Ministry of Finance also hosted a roundtable with stakeholders on key issues in March These efforts focused on potential updates to the SABS catastrophic impairment definition, rather than other structural changes such as modifying accident benefit limits available for catastrophic impairment or allowing courts to determine awards to seriously injured drivers and giving consumers more choice to purchase the coverage that meets their needs. Section compares Ontario s accident benefits regime for catastrophic impairment with those in other Canadian provinces with privately delivered auto insurance. Appendix 7 contains catastrophic impairment data. Bodily Injury Claims Study In 2013, FSCO undertook a third party liability bodily injury claim study. The recently completed study provides more information for the government, the insurance industry and other stakeholders on the costs and factors contributing to bodily injury claims. The last comprehensive study examined closed claims from Following a public tender, Pinnacle Actuarial Services was selected to conduct the study. Pinnacle conducted an extensive survey of closed and open claims from 2005 bodily injury claims involving automobile insurers in Ontario representing over 85% of the 2005 auto market share. Pinnacle s report on the study was completed in 2014 and is posted on FSCO s website at Recommendation 1 The government should continue to closely monitor Ontario s auto insurance system, claims costs, and activity of participants in the system and make timely legislative and regulatory changes to address emerging problems, issues or areas of rising costs. 16 Report of Inquiry into Motor Vehicle Accident Compensation in Ontario, 1988 Report on the Three Year Review of Automobile Insurance, 2014 Page 22
23 Although government has taken critical steps to improve auto insurance affordability, continued monitoring of Ontario s auto insurance system can help identify further system changes that may be needed to avoid a repeat of past cost reform cycles. Areas where the government could consider making additional reforms to further contain claims costs, increase consumer choice, and achieve other system improvements are highlighted in the report, including: Statutory accident benefits (Sections 5.1 & 5.2, Recommendation 3); Consumer choice around auto insurance coverages (Section 5.2, Recommendation 4); Consumer and auto insurance stakeholder education around treatment and recovery (Section 5.3.1, Recommendation 5); The tort (bodily injury) system (Section 7, Recommendation 7); and, Standard deductible levels for physical damage related coverages (Section 8.3, Recommendation 8). Recommendation 2 All participants in the auto insurance system have a responsibility to continue to focus on reducing and controlling auto insurance costs and dealing with the ongoing challenges associated with fraud and misuse of the system. Areas where participants in the auto insurance system can take leadership and contribute to a well-functioning and affordable auto insurance system are identified throughout this report, including: Assessments and examinations (Section 6, Recommendation 6); Auto insurance claims adjustment and handling (Section 9, Recommendation 9); and, Taxi insurance availability and optional insurance coverages for rental vehicles (Section 10, Recommendation 10). 4 Ontario s Experience Compared to Other Jurisdictions Affordability and availability pressures in the auto insurance system are not unique to Ontario. All jurisdictions experiencing cost pressures must grapple with the design of their auto insurance systems and how those systems interact with health care systems, road safety mechanisms, the legal system, and behaviour of system participants. Report on the Three Year Review of Automobile Insurance, 2014 Page 23
24 4.1 System Comparison to Provinces with Privately-Delivered Auto Insurance The auto insurance systems in Alberta, Nova Scotia, Prince Edward Island (PEI) and New Brunswick are considered comparable due to structural similarities to Ontario s framework (e.g., privately delivered auto insurance and mandatory no-fault accident benefits together with some degree of access to tort). When compared to other provinces that have privately-delivered auto insurance Alberta, Nova Scotia, PEI, New Brunswick, and Newfoundland and Labrador Ontario s system provides the most generous package of mandatory accident benefits, including a higher tier limit for medical-rehabilitation coverage for catastrophic impairments, a separate benefit for attendant care, and a longer timeframe in which to access medicalrehabilitation benefits. Alberta, Nova Scotia, PEI and New Brunswick have fewer restrictions on the right to sue and a smaller set of accident benefits. Newfoundland and Labrador primarily has a tortbased (third-party liability) system with optional accident benefits. Appendix 8 of this report compares key accident benefit coverages in Ontario and other provinces with privately-delivered auto insurance. Ontario is the only such province that offers a comprehensive and formal alternative dispute resolution system for insurer-claimant disputes over accident benefits. Ontario is further differentiated by its large metropolitan centres. Increased densities in large urban cities may result in more traffic, collisions, opportunities for system participants to interact, and different auto insurance dynamics. 4.2 Experience in the UK and Select US Jurisdictions In the United Kingdom (UK), motor insurance cost increases have been linked to fraudulent and exaggerated motor insurance claims, particularly for whiplash injuries. Certain practices by system participants have also been identified as likely contributing factors. These include insurer business practices of settling whiplash cases before a medical assessment, and UK solicitors offering inducements to people considering making claims. 17 In the US, jurisdictions such as Michigan, New York and Florida also appear to be wrestling with rising costs of auto insurance claims. In 2013, New York adopted new regulations allowing investigation of healthcare providers participating in the no-fault 17 Driving premiums down: fraud and the cost of motor insurance, House of Commons Transport Committee, July Report on the Three Year Review of Automobile Insurance, 2014 Page 24
25 auto insurance system and banning fraudulent providers from receiving payment from insurers. 18 In 2012, Florida passed legislation to reduce medical care limits for nonemergency treatment, restrict attorney fee awards in individual and class action no-fault disputes, and increase penalties for licensed health care practitioners who are found guilty of fraud. 19 Michigan, which is the only state that mandates unlimited, lifetime medical and rehabilitation coverage, has considered reforms such as creating an antifraud authority, introducing fee schedules for medical services, and placing restrictions on some accident benefit coverages Claims Costs Comparison to Provinces with Privately-Delivered Auto Insurance Although reforms and ongoing initiatives have reduced claims costs for private passenger vehicles since 2010, Ontario continues to have the highest per-vehicle claims costs compared to other Canada provinces with privately-delivered auto insurance. Ontario s average claims cost per private passenger vehicle was about $1,000 over the 2011 to 2013 accident year period. This is approximately 20% higher to over twice the costs than in comparable provinces. Chart 5 illustrates these differences. Appendix 9 compares private passenger vehicle claims costs and premiums of these provinces in more detail. Ontario s higher total claims costs are linked to higher payouts on accident benefit claims as well as high payouts on bodily injury (tort) claims. As shown earlier in Chart 3, these two coverages accounted for 64% of total claims costs in the 2013 accident year. A more detailed discussion on accident benefits and tort (bodily injury) claims is found in the next three sections. 18 Insurance Regulation 68-E (11 NYCRR 65-5), Unauthorized Providers of Health Services, New York State Department of Financial Services Florida House Bill 119, Motor Vehicle Personal Injury Protection Insurance Michigan House Bill 4612 (2013) and Michigan Senate Bill 818 (2014). e=2013-hb me=2014-sb-0818 Report on the Three Year Review of Automobile Insurance, 2014 Page 25
26 Chart 5 Source: 2013 General Insurance Statistical Agency exhibit for private passenger vehicles. 5 Accident Benefits Benefits defined in Ontario s SABS are designed to compensate claimants for eligible medical and rehabilitation expenses that are reasonable and necessary in order to aid recovery from an injury sustained in a motor vehicle accident. Statutory accident benefits also cover eligible economic losses, such as income replacement benefits, death and funeral benefits, lost education expenses, and replacement of certain goods, such as eyeglasses. 5.1 Accident Benefit Claims Experience for Private Passenger Vehicles Changes in Claims and Frequency 21 Accident benefit claims costs for private passenger vehicles grew rapidly from $1.60 billion in the 2004 accident year to $3.78 billion in the 2010 accident year, an increase of approximately 137%. These costs rose as a result of increases in both the number of claims (from 62,529 to 79,882) and average per-claim cost (from $25,522 to $47,366, peaking in the 2009 accident year at $51,851). These trends contrast with a general decrease in individuals reported as injured in motor vehicle collisions. As noted earlier, the Superintendent s 2009 Report on the Five Year Review of Automobile Insurance and the AFTF attributed these increases to overutilization in the system and fraud. After the government s 2010 reforms and subsequent measures to reduce costs, accident benefit claims costs for private passenger vehicles fell from $3.78 billion in the 21 All data from General Insurance Statistical Agency exhibits for private passenger vehicles. Report on the Three Year Review of Automobile Insurance, 2014 Page 26
27 2010 accident year to $1.92 billion in the 2012 accident year. However, accident benefit costs are again beginning to move upward. In the 2013 accident year they rose by approximately 12% to $2.15 billion. The number of claims and average per-claim cost also decreased between the 2010 and 2012 accident years, and then started to rise in the 2013 accident year. With this decrease, accident benefit claims costs are the second largest portion of total claims costs, accounting for approximately 30% in the 2013 accident year. Bodily injury claims costs represent the largest portion and account for approximately 34% of total claims costs. Table 2 - Accident Benefit Claims Experience (private passenger vehicles) No. of AB claims 62,529 73,564 79,882 62,840 67,541 No. of AB claims per 100 earned vehicles Average AB cost per claim $25,522 $51,851 $47,366 $30,549 $31,786 Average AB cost per insured $269 $588 $576 $283 $313 vehicle Total AB claims costs $1.60 B $3.81 B $3.78 B $1.92 B $2.15 B Changes in Specific Accident Benefit Coverage Costs Following the 2010 reforms, decreases in accident benefit claims costs for private passenger vehicles were seen in medical benefits, exams and assessments, and housekeeping between the 2010 and 2013 accident years. Claims costs for other accident benefit coverages also decreased due to other cost controls implemented in 2010 and reduced overuse and fraud in the system shown in Chart 6. Report on the Three Year Review of Automobile Insurance, 2014 Page 27
28 m1%00 Physical Damage Claims Costs Remained Relatively Unchanged While Accident Benefits Claims Costs Changed Significantly between Physical Damage Costs Chart 6 Accident Benefits Costs ,7% _46.0% WO % 9.5% 4.5% 5.0% % _ ; % -18.6% 24 7% -19A% -234% 17.1% i I rinr-ln 265.2% _97.7% I % -99.5% Comprehensive Collision Direct Compensation Medical Exams& Assessments Attendant Care Income Replacement Housekeeping Caregiver , _ - - a Sources: Ontario Auto Insurance Anti-Fraud Task Force, Interim Report, December 2011 and General Insurance Statistical Agency exhibits for private passenger vehicles. Claims and Dispute Trends in the Greater Toronto Area The number and cost of accident benefit claims for private passenger vehicles grew more rapidly in the Greater Toronto Area (GTA) than the rest of the province prior to and during the 2010 accident year (see Chart 7). However, these have now decreased in the wake of the 2010 reforms and other ongoing initiatives. Although claims costs have decreased on average in the GTA, individual policyholders may experience premium decreases or even increases at policy renewal based on several factors, such as changes in individual circumstances (coverages and deductibles chosen, vehicle insured, driving experience, other risk factors) and the claims experience of their particular insurer. Other recent reports and reviews also identified differences between auto insurance claim costs and disputes in various areas of Ontario, particularly when comparing the GTA to other parts of the province. The AFTF noted that the GTA accounted for $1.7 billion (out of $2 billion) in unexplained accident benefit costs from 2006 to 2010 accident years. The DRS review noted that the while around 50% of accident injuries occur in the GTA, 80% of dispute applications (both mediation and arbitration) originate in the GTA. Report on the Three Year Review of Automobile Insurance, 2014 Page 28
29 Chart 7 Source: General Insurance Statistical Agency exhibits for private passenger vehicles. GTA = statistical territory 717, which includes Metropolitan Toronto and Markham, Richmond Hill, Vaughan, and Peel Districts. 5.2 Comparison to Other Provinces with Privately-Delivered Auto Insurance Despite the success of the 2010 reforms and other recent actions, average accident benefit claims costs for private passenger vehicles in Ontario continue to be higher than those in other Canadian provinces with privately-delivered auto insurance. Additionally, these costs rose in the 2013 accident year compared to Average accident benefits claims costs per private passenger vehicle were $305 over the 2011 to 2013 accident year period which ranges from about 5 to 10 times higher than in comparable provinces. Chart 8 illustrates these differences. Report on the Three Year Review of Automobile Insurance, 2014 Page 29
30 Chart 8 Source: 2013 General Insurance Statistical Agency exhibit for private passenger vehicles. As noted earlier, Ontario provides the most generous package of mandatory accident benefits than comparable provinces. The following section compares key features of statutory accident benefit coverages and accident benefits systems in Ontario and other provinces Key Accident Benefits Ontario has more generous key accident benefits coverages than in comparable provinces. Although Ontario s standard medical and rehabilitation benefit limit of $50,000 is equivalent to the limits in Alberta, Nova Scotia, New Brunswick and PEI, Ontario has the only system that provides a higher tier limit of $1,000,000 for catastrophic injuries. Additionally, Ontario has a separate attendant care benefit that is not included in the medical and rehabilitation limit a maximum of $36,000 for non-catastrophic injuries (available over 2 years), and an additional $1,000,000 maximum for catastrophic injuries (no time limit). Ontario also has a higher maximum income replacement benefit (IRB) which provides compensation for lost income due to an injury incurred in an auto accident. Table 3 shows that maximum compensation available under Ontario s IRB is more generous than in comparable provinces. For example, even though Alberta provides an identical monetary limit to Ontario ($400/week) for IRBs, Ontario provides the benefit for a partial disability for 104 weeks, and if totally disabled, there is no time limit. By comparison, Alberta does not provide any benefit for partial disability and limits the payout if totally Report on the Three Year Review of Automobile Insurance, 2014 Page 30
31 disabled to 104 weeks. 22 While Nova Scotia, PEI and New Brunswick provide identical time payment limitations as Ontario, their income replacement limits are substantially lower at $250/week. Table 3 Income Replacement Benefits Province ON AB NS PEI NB Benefit Calculation 70% of gross income less amounts available for loss of income from all other sources 80% of gross income less any payments for loss of income from employment received by or available to such insured person 80% of net income less any payments for loss of income from other sources 80% of net income less any payments for loss of income from other sources 80% of net income less any payments for loss of income from other sources Weekly Limit Partial disability time limit $400/week 104 weeks None $400/week No benefit available for partial disability $250/week 104 weeks None $250/week 104 weeks None $250/week 104 weeks None Total disability time limit 104 weeks Duration of Medical and Rehabilitation Benefits The maximum timeframe for Ontario accident benefit claimants to have their medical and rehabilitation costs paid is longer than in comparable systems. The standard medical and rehabilitation benefit in Ontario can be paid for a period of 10 years and, if the claimant has a catastrophic injury, it can be paid for as long as the claimant continues to qualify, up to the policy limit. In contrast, in Alberta, the medical and rehabilitation benefit of $50,000 is only available in the 2 year period after an accident. In Newfoundland and Labrador, Nova Scotia, New Brunswick and PEI it is available for a period of up to 4 years after the accident Eligibility Test for Other Goods and Services To be eligible for any medical and rehabilitation goods and services in Ontario, the proposed expense must meet a test of being reasonable and necessary. In Alberta, Nova Scotia, New Brunswick and PEI, the eligibility requirement for core medical, surgical, dental, chiropractic, ambulance, hospital, or professional nursing 22 IRBs could be higher in other provinces on a weekly basis in certain circumstances. Report on the Three Year Review of Automobile Insurance, 2014 Page 31
32 services is similar to Ontario s reasonable and necessary test. However, unlike Ontario, other goods and services in those provinces are subject to a stricter eligibility test that requires the expenses to be essential for treatment and rehabilitation of the injured person. In addition to this stricter eligibility test, the opinion must be shared by the claimant s physician and the insurer s medical adviser in order for the expense to be paid. Recommendation 3 The government should examine and consider the accident benefits structures of comparable auto insurance systems in Canada that have lower costs. Potential changes that could be considered to more closely align Ontario s accident benefits system with comparable provinces include: Modifying catastrophic impairment accident benefit limits or allowing courts to determine awards to seriously injured drivers and giving consumers more choice to purchase the coverage that meets their needs; Combining medical-rehabilitation and attendant care benefits or limits; Reducing the duration of medical-rehabilitation benefits for non-catastrophic impairments; and, Introducing a stricter eligibility test for other goods and services. Recommendation 4 The government should examine and consider giving consumers more flexibility and choice to buy coverage options that reflect their individual circumstances and needs. In tandem with any changes to statutory accident benefits, consumers should have the choice to buy expanded benefits and levels. Report on the Three Year Review of Automobile Insurance, 2014 Page 32
33 Reforming the mandatory benefits structure could impact the Motor Vehicle Accident Claims Fund (MVACF) 23 in costs paid out for accident benefit and bodily injury claims. In addition, possible MVACF claimants may be impacted by their ability to access optional benefits Treatment Planning and Approval Health care professionals play a critical role in the recovery of claimants injured in a motor vehicle accident through treatment and assessment services. In Ontario, there are 26 regulated health professionals that can prepare treatment plans for claimants under the SABS. Of these, nine are designated as health practitioners who can certify treatment plans, as well as disability for income replacement and non-earner benefits. Insurers can also approve care and treatment provided by unregulated health professionals. At the end of July 2014, 30,588 unique health care professionals were registered in the Health Claims for Auto Insurance system (HCAI) roster. HCAI is used to transmit claim forms electronically to insurers, so the number of registrants in the roster reflects the number of health care professionals that can participate in the auto insurance system. These registrants provide services to about 62,000 injured persons each year, the vast majority of whom (96%) were reported as having minimal or minor injuries. 24 The number of registrants may increase with the planned expansion of the number of regulated health professions in Ontario to include homeopaths, naturopaths and psychotherapists. Approaches to Treatment in Comparable Provinces The variety of regulated health professionals able to approve treatment plans for auto accident claimants contrasts sharply with comparable provinces. In Alberta, within the Diagnostic and Treatment Protocols Regulation (DTPR), treatment approvals are limited to three regulated health professions physicians, chiropractors and physical therapists within their scope of practice. The DTPR establishes a set block of 10 or 21 treatments, depending on the severity of the minor injury. Health care professionals can refer DTPR patients to other treatment providers such as massage therapists, within the specified 10 or 21 treatments. Treatments under the DTPR are not subject to insurer approval. If the health care professional is uncertain about the injury, or if the injury is not resolving appropriately or in the time expected, they may refer a patient to an Injury Management Consultant (IMC) also a physician, chiropractor or physical therapist who can recommend additional treatment options. Referrals to an IMC are not subject to insurer approval, as long as they occur prior to the conclusion of the 10 or MVACF provides compensation to people involved in automobile accidents when no other automobile insurance exists to respond to claims. 24 Based on Ontario Road Safety Annual Report 2011 Report on the Three Year Review of Automobile Insurance, 2014 Page 33
34 treatments and within 90 days of the accident. The purpose of the referral is to establish or confirm a diagnosis and/or provide recommendations on the best treatment options to facilitate recovery, not to gain approval for additional treatment beyond the original 10 or 21 treatments. In effect, the IMC is a second opinion to assist the treating health professional. Outside of the DTPR anyone who provides necessary medical, surgical, chiropractic, dental, hospital, psychological, physical therapy, occupational therapy, massage therapy, acupuncture, professional nursing and ambulance services can recommend treatment, provided the expense is reasonable. For other services outside of this list, only the insured person s attending physician together with the insurer s medical advisor can authorize treatment. Nova Scotia has a treatment protocol based on Alberta s protocol described above. In both Alberta and Nova Scotia, the protocols are reported to be voluntarily and widely used. New Brunswick plans to establish a protocol similar to Alberta and Nova Scotia. In Alberta, both the protocol and an accompanying health care practitioners guide emphasize the importance of patient education, and expect health practitioners to educate their patients about the nature of their injuries. Nova Scotia s protocol also outlines expectations around patient education in relation to a number of injuries common to motor vehicles accidents. 5.3 Experience with the Minor Injury Guideline The current minor injury definition, MIG and a $3,500 limit on medical and rehabilitation benefits for minor injuries were introduced in September 2010 as part of a broad package of auto insurance reforms. Goods and services provided under the MIG are subject to a streamlined pre-approved process that facilitates quick access to treatment and rehabilitation. As the vast majority of people injured in auto collisions are reported to have injuries that are minimal or minor 25, it is expected that the MIG applies to most claimants. During consultation for this report, differing views were expressed around the MIG, the minor injury definition, and the $3,500 limit for medical and rehabilitation benefits. Some health care provider organizations, consumers, and an association of legal representatives for plaintiffs have suggested that some claimants with minor injuries may need more treatment than is currently offered by the MIG. It was also suggested that some insurer examinations to determine whether a claimant has a minor injury may not necessarily be conducted by objective assessors and that not all assessors are equally qualified. The recently clarified requirement for documentation prior to the accident to support pre-existing conditions was also noted as a stringent requirement. In contrast, insurers reported that the minor injury definition is being challenged and may erode over time, particularly for minor psychological conditions. 25 Ontario Road Safety Annual Report 2011 Report on the Three Year Review of Automobile Insurance, 2014 Page 34
35 The number of mediation applications regarding the MIG appears to be increasing from 2% of applications received in 2013 to about 8% of applications received from January to September Between January and September 2014, 5% of mediation cases proceeded to arbitration based solely on a MIG dispute. Ongoing monitoring of MIG related disputes is required as the auto insurance system continues to transition to the post-2010 accident benefits regime. Ontario s experience with the MIG contrasts with the experience noted above in Alberta and Nova Scotia Education of System Participants around Treatment and Recovery Consumers, health care providers, and insurers would benefit from improved information and dialogue about appropriate and necessary treatment of minor injuries common to motor vehicle accidents. This will help inform expectations about treatment type, frequency and length, as well as recovery outcomes. As noted earlier, Alberta expects health care providers to educate claimants about the nature of their injuries. The Senior Medical Advisor to the Superintendent of Insurance in Alberta has issued a health practitioner s guide regarding treatment, which includes specific points about patient education. Nova Scotia s protocol has similar expectations for health care providers around patient/claimant education. Recommendation 5 The Ministry of Finance and FSCO should work with experts to develop a program to educate consumers and auto insurance stakeholders about expectations for treatment and recovery following a motor vehicle accident. Any education program should include relevant findings from the Minor Injury Treatment Protocol project. 6.0 Assessments and Insurer Examinations Accident Benefits Assessments and Insurer Examinations In Ontario, an assessment or insurer examination conducted in relation to an accident benefit claim is a clinical evaluation of a claimant s health status and may be requested by a claimant or their health care provider (assessment) or an insurer (IE). Report on the Three Year Review of Automobile Insurance, 2014 Page 35
36 Assessments and IEs may be conducted in relation to claims for medical and rehabilitation benefits, attendant care benefits, income replacement and other benefits, and catastrophic impairment status. The costs of claimant-initiated assessments are included in the available medical and rehabilitation benefits of $3,500 for minor injuries, $50,000 for serious injuries and $1,000,000 for catastrophic injuries. This means funds spent on assessments are not available to treat a claimant. The costs of IEs are not deducted from medical and rehabilitation benefits that are available to injured drivers. In the 2010 reforms, a $2,000 cap on accident benefits assessments and IEs was implemented to help control costs. Accident Benefit Assessment and Insurer Examination Costs Assessment and IE costs continue to be a cost driver in the accident benefits system as shown in Table 4. Table 4 - Examination Claims Experience (Private Passenger Vehicles) by Accident Year No. of examination claims 36,448 47,375 48,970 31,070 36,127 No. of claims per 100 insured vehicles Average cost of examinations per insured vehicle $41.94 $ $ $41.74 $50.60 Total examination costs $248.6 million $846.2 million $847.1 million $282.8 million $346.9 million Total AB claims costs $1.60 B $3.81 B $3.78 B $1.92 B $2.15 B Source: 2013 General Insurance Statistical Agency exhibits for private passenger vehicles. The Ontario Health Claims Database (HCDB) Standard Report, produced by the Insurance Bureau of Canada (IBC), reports on automobile insurance health claims data submitted through HCAI. It also illustrates the high costs paid for assessments and IEs in the adjustment of accident benefit claims 26 by reporting on billing and payments for accidents that occurred on or after January 1, To date, 2011 is the year with the most claims development so it is most representative of ultimate costs. In that year, the HCDB reported an average cost of $4,932 per IE claimant and $1,319 per assessment claimant (as of July 30, 2014). 27 These figures do not include the costs of cancelled and missed appointments. 26 The HCDB system collects and reports up-to-date information on the expenses paid by insurers on select medical and rehabilitation expenses billed through HCAI. It does not include any reserves or project future claims development to ultimate costs. 27 Insurance Bureau of Canada, Ontario Health Claims Database HCDB Standard Report 2014-H1 August 2014 Report on the Three Year Review of Automobile Insurance, 2014 Page 36
37 Missed or Cancelled Appointments As of June 30, 2014, over 12,700 or about 21.5% of claimants injured in 2011 had missed or cancelled appointments, resulting in costs of $16.7 million. 28 The average cost paid by insurers was over $1,300 per claimant who missed or cancelled one or more appointment. The Professional Services Guideline, most recently issued by the Superintendent in September 2014, confirmed that insurers are not liable for the cost of missed or cancelled appointments for assessment or treatment by a health care provider. The Professional Services Guideline does not apply to missed IEs, which likely account for the majority of missed or cancelled appointments reported through the HCDB Standard Report. Missed IEs may be subject to contractual terms set out between individual insurers and IE providers. The AFTF heard that claimants may be counselled by their legal advisers to avoid attending IEs, and noted that intentional non-attendance adds costs to the auto insurance system and increases premiums for all drivers. 29 The AFTF recommended that insurers be allowed to collect a $500 cancellation fee from claimants who fail to attend IEs without a reasonable notice or explanation. Critical Role of Assessments and Insurer Examinations Assessments and IEs are important to both health care providers and insurers in evaluating and assessing eligibility and needs of claimants. Health care providers must examine and assess claimants to diagnose and recommend a proper course of treatment and assess disability. Insurer examinations are used to respond to applications for benefits or to determine whether a claimant is, or continues to be, entitled to a benefit. Although IEs are not required to gain access to services, insurers often request an IE to substantiate certain medical and rehabilitation claims, particularly if an injured person seeks treatment beyond the MIG, is not recovering as expected, or is seeking a determination of catastrophic impairment. IEs can help prevent over-treatment and unnecessary costs. Assessors The DRS review noted that assessors in Ontario s auto insurance system should be impartial, and recommended that experts should be required to certify their duty to the proposed Tribunal to provide fair, objective and non-partisan evidence. 30 The AFTF recommended that the regulatory health colleges work together to develop professional 28 Insurance Bureau of Canada, Ontario Health Claims Database HCDB Standard Report 2014-H1 August Ontario Automobile Insurance Anti-Fraud Task Force, Final Report of the Steering Committee, Ontario Automobile Insurance Dispute Resolution System Review, Final Report, 2014 Report on the Three Year Review of Automobile Insurance, 2014 Page 37
38 standards and training, guidelines, and best practices to improve the quality of independent medical assessments of auto insurance claimants conducted by their members. 31 Stakeholder feedback Through consultation for this report, some stakeholders noted cost, quality and frequency concerns around assessments and examinations, as well as qualification and impartiality of assessors. The high number of IEs and other assessments appears to contribute to an adversarial climate between claimants and their auto insurers. Experience in Comparable Provinces The high cost of assessments and examinations appear to be an Ontario phenomenon. Other provinces with comparable provinces do not have similar cost pressures associated with assessments or IEs. This is likely linked to a number of structural and other differences in their auto insurance systems. As noted earlier, treatment protocols in Alberta and Nova Scotia are widely used. In Alberta and Nova Scotia, secondary assessments or examinations regarding accident benefits claims are conducted by an Injury Management Consultant (physician, chiropractor or physical therapist) who has met criteria approved by their respective regulatory college. In Alberta, assessments regarding minor injury designation for the purpose of tort (bodily injury) claims are conducted by a Certified Examiner. Certified Examiners are physicians who have not treated or been consulted on the diagnosis or treatment of the claimant being assessed for minor injury designation, and who meet criteria approved by their regulatory college. The opinion of the Certified Examiner is accepted as prima facie evidence (accepted as correct unless proven otherwise) in court. 31 Ontario Automobile Insurance Anti-Fraud Task Force, Final Report of the Steering Committee, 2012 Report on the Three Year Review of Automobile Insurance, 2014 Page 38
39 Recommendation 6 Health care and insurer representatives should jointly examine and make recommendations on: a) appropriate qualifications for auto insurance examiners b) standards and processes in requesting, writing and delivery of auto insurance assessments and examinations c) frequency and costs associated with auto insurance assessments and examinations, including missed or cancelled appointments Health care and insurer representatives could examine the current $2,000 cap, the number of assessments and examinations, and mechanisms by which insurers can address missed IE costs through contractual arrangements. Improvements and controls in the quality, number and cost of assessments and examinations, including missed or cancelled appointments, could help reduce overall cost pressures in the auto insurance system. As well, when a claim is disputed in the DRS or in court, both sides rely on their own expert medical witnesses. This compounds the assessment and IE costs in both the accident benefit system and bodily injury (tort) cases. There are no established limits for plaintiff or defendant costs for expert medical witnesses in the tort system. Associated costs may be included in plaintiff legal costs and bodily injury claim costs paid for by insurers. The bodily injury side of automobile insurance is discussed in the following section. 7.0 Bodily Injury (Tort) In Ontario, if a person is injured in an accident, and is not at-fault for the accident, they are eligible to sue the at-fault driver for economic loss or health care expenses in excess of their accident benefit coverages and for pain and suffering, subject to certain limitations. In order to sue for excess health care expenses and for pain and suffering, the injuries of the injured person must meet a verbal threshold of permanent serious disfigurement, or permanent serious impairment of an important physical, mental, or psychological function, or, death. A $30,000 deductible applies to court awards for pain and suffering (or $15,000 for family members under the Family Law Act). This deductible does not apply for pain and suffering awards if the damage award exceeds $100,000 (or $50,000 for family Report on the Three Year Review of Automobile Insurance, 2014 Page 39
ONTARIO AUTO INSURANCE REFORM: A GAME OF WHACK-A-MOLE *
ARTICLES ACADÉMIQUES ACADEMIC ARTICLES Assurances et gestion des risques, Juillet-Décembre 2015, Vol. 82 (3-4) Insurance and risk management, July-December 2015, Vol. 82 (3-4) ONTARIO AUTO INSURANCE REFORM:
3.13. Recovery of Health Costs Resulting from Accidents. Chapter 3 Section. Background. Ministry of Health and Long-Term Care
Chapter 3 Section 3.13 Ministry of Health and Long-Term Care Recovery of Health Costs Resulting from Accidents Background The Ministry of Health and Long-Term Care (Ministry) has the legal authority to