Toronto Personal Injury Lawyer Albert Conforzi: Last week, yet another shady trend in insurer behaviour came to light.
Under the standard automobile policy, insurers provide accident benefit coverage for such things as attendant care, income replacement benefits, and medical/rehabilitation benefits. The specific items that qualify as a medical/rehabilitation benefit are set out in s.14 of the Statutory Accident Benefits Schedule (SABS). They include “medical, dental, optometric, hospital, nursing, ambulance, audiometric and speech language pathology service[s],” as well as “other goods and services of a medical nature that the insured person requires.” Emphasis mine.
It has come to my attention that some, but not all, insurers are paying for medical records obtained by them by making the payments from the med/rehab benefit entitlements.
What this does is effectively short-change the insured in accessing their limits of coverage under this provision. It takes money that is supposed to be used for therapies to assist with recovery, and uses that money to pay for items that are not covered by the section. Worse yet, the insurers are not telling their insured clients about it. They are not sending out explanation of benefit forms, as they would be required to do when paying out a benefit, and when they are called to task on this corrupt behaviour, they simply ignore the complaint.
Insurers these days are secure in the knowledge that the backlog of processing mediations of accident benefits disputes at the Financial Services Commission gives them a year-long delay in having to face the reality of their actions. They seem to have it in their heads that they can act with impunity.
They are dealing from the bottom of the deck. Now that is a real world example of insurance fraud.