Ontario DACs to be eliminated March 1, 2006

The Financial Services Commission of Ontario (FSCO) has amended the Statutory Accident Benefits Schedule (SABS) to eliminate the DAC system effective March 1, 2006, subject to transition provisions.The new regulations will continue to require a claimant to obtain an assessment from his or her own health care provider when applying for benefits, FSCO has announced on its Web site.An insurer that wishes to review or challenge the findings of an assessment or an ongoing benefit will be required to request a separate medical or health care examination from a health care provider of the insurer’s choice prior to making a determination on benefit entitlement. Benefits that are the subject of the insurer examination review must continue to be paid while the insurer’s examination is in progress and until the claimant is notified of the insurer’s benefit determination. The regulation requires the insurer to provide a copy of the examination report and insurer’s determination to the claimant and the original health care provider.A dispute over assessment or examination findings or benefit determinations will proceed directly to the dispute resolution system at FSCO.Additional SABS amendments include a pre-claim examination that can be undertaken by an insurer with the consent of the claimant. The intent is to assist in determining benefit eligibility and expediting the provision of goods and services following an accident, as well as in situations where a claimant has been admitted to a hospital or is being discharged.Also, the SABS has been amended to remove the prohibition on filing for mediation because of non-attendance by a claimant at an insurer examination. Under amendments to Regulation 664, claims involving non-attendance at insurer examinations will instead be subject to cost sanctions at arbitration. A claimant that does not attend an insurer examination will continue to be subject to the suspension or stoppage of benefit payments during the non-attendance period.Finally, the SABS has been amended to expand the list of unfair and deceptive acts and practices. Many of these changes are aimed at preventing delays or the possible misuse of insurer examinations. Changes include the determination that a person is not entitled to a benefit before obtaining an insurer examination report as required in the regulation.