A New Auto Insurance Assessment Model-

2 Lansing Square, Suite 304
Toronto, Ontario M2J 4P8
Tel: 416-489-0711 Fax: 416-489-7009
Website: www.omegamedical.ca

January 6, 2014

Senior Manager
Automobile Insurance Policy Unit
Industrial and Financial Policy Branch
Ministry of Finance
95 Grosvenor Street, 4 th Floor
Toronto, ON M7A 1Z1

RE: Ontario Automobile Insurance Dispute Resolution System Review Submissions

I am a physician-stakeholder with extensive involvement in the assessment of injured motor-vehicle
accident claimants under Ontario’s No-Fault Insurance system.
My particular professional interest has been in the assessment of claimants injured in automobile
accidents and in their access to reasonable and necessary benefits under all of the No Fault auto
insurance schemes introduced since 1990 of Ontario. More recently, I have made submissions to FSCO
regarding their Report of the Catastrophic Impairment Expert Panel to the Superintendent as well as to
the Legislative Standing Committee on Finance and Economic Affairs.
My extensive involvement over the past two and a half decades as a physician stakeholder has given me
a unique yet independent perspective on some important matters. In particular, I would like to submit
for your review my thoughts on improving the “Independent Medical Examination” issue. My
recommendations are simple: Reconstruct the previous extensively developed and successful DAC
system, with some relatively minor changes to address concerns of insurers and plaintiff’s counsel,
adjust the vetting system by FSCO of rostering physicians and other health professionals, and meld this
with a variant of the fairly simple system introduced in the state of Colorado almost twenty years ago.
Who am I to suggest a new assessment model?
I am an adjunct assistant professor in the Faculty of Medicine at the University of Toronto. I am also a
trained scientist with a rigorous undergraduate science education and two advanced post-graduate
degrees including a PhD in Medical Biophysics.
I am a past president of the Medicolegal Society of Toronto.
I have spent more than 20 years working exclusively in the assessment of claimants under the various
No Fault Auto Insurance schemes since the Ontario Motorist Protection Plan was launched in 1990. I
was the Ontario Medical Association’s representative on the Minister’s Committee for the Designated
Assessment Centre System (Minister’s DAC Committee) from 1996 through 2001, retiring as Vice Chair.
While a member of the Minister’s DAC Committee, I was the chair of the working group that authored
the Catastrophic Impairment Assessment Guidelines used throughout Ontario until the DAC system was
disbanded in 2006. I also served as the medical representative on the Advisory Panel that wrote the
Report on the Redefinition of Catastrophic Impairment to the Minister of Finance released in 2001.Dr. Harold Becker
A New Auto Insurance Assessment Model
One problem that requires fixing -- the “Independent Medical Examination”
There have been ongoing concerns regarding the quality and independence of medical examinations of
injured claimants. So much so that the term “IME” no longer represents “Independent Medical
Examination” but is now used to represent “Insurer Medical Examination”. The integrity of the system
used to evaluate access to insurance benefits has lost the confidence of consumers.
For years, the insurance industry has relied on a model of IME’s in their efforts to adjudicate payment of
benefits to injured claimants. This used to involve the insurers’ choice of assessor but evolved into a
“broker” system where insurers chose an assessment company who then assigned an assessor to the
referral. In my opinion, and in the opinion of many legal representatives, this was a simple yet veiled
attempt for insurers to “insulate” themselves from accusations of preferentially selecting IME providers
who would provide preferred opinion to them. While this allowed insurers to pretend they were
isolated from those actions, in fact, the move to IME “brokers” merely moved the accusations of bias
from single assessors to assessment companies.
Successful past models for IME’s
In 1994, a brilliant assessment model was introduced in Ontario, a model that addressed issues of
selectivity and quality of independent assessment of accident victims. This was the “DAC” (Designated
Assessment Centre) system which was overseen by the Minister of Finance through the establishment of
a Minister’s DAC Committee. I have written additional details of the work of the DAC Committee further
in this document.
The DAC system for more than ten years, from 1994 through 2006, and developed extensive
infrastructure for assessment of claimants. Guidelines for assessment for med-rehab, disability, and
attendant care benefits as well as access to catastrophic impairment designation were extensively
developed and fine-tuned. In turn, these underwent legal interpretation via arbitration decisions. The
DAC system evolved into a comprehensive and successful structure of claimant evaluation before it was
finally disbanded by FSCO. Nothing was put in its place and the present IME system has prevailed
subsequently.
In 1996, an American Model for independent medical evaluation was developed by the State of
Colorado. This, too, evolved out of dissatisfaction of perceived bias of insurers in determining access to
auto insurance benefits by claimants. The “Colorado Model” provided claimants with an independently
developed list of five authorized “IME” health professionals. The list was “whittled down” by each side
deselecting two names at a time until the last name on the list became the de facto IME provider.
I have provided some material on the Colorado Model in Appendix II and III.
The historical evolution of the assessments of claimants over the past 20 years.
The assessment of insured claimants is seen by many to be problematic and has been so for many years.
While the insurance industry has tackled the problem for decades, the issue has become more difficult
than ever as the assessment of accident victims has evolved far beyond the single orthopedic
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A New Auto Insurance Assessment Model
examination of the 70’s and 80’s to now involve more advanced and increasingly complex
multidisciplinary evaluations. This shift has come about as a result of advances in evidence-based
medicine that acknowledges that there is much more to accident-related injuries than what was
appreciated as “whiplash” in decades past. Many frontline studies have shown that recovery from
complex injuries must involve a multidisciplinary approach to rehabilitation that includes not only
physical and psychological recovery but also functional restoration.
Indeed, the Statutory Accident Benefits Schedule directs rehabilitation “that (is) reasonable and
necessary for the purpose of reducing or eliminating the effects of any disability resulting from the
impairment or to facilitate the person’s reintegration into his or her family, the rest of society and the
labour market.”
In an important acknowledgement, the Insurance Bureau of Canada (IBC) in their submission to you has
recommended the Creation of a Medical Expert Panel (see Appendix I). Their submission states, in part:
“Currently arbitrators do not have access to a neutral benchmark for the generally
expected medical course for claims under the SABS. We propose engagement of an
independent and unbiased medical expert panel, mandated to provide insight on the
evidence-based state of medical knowledge. The panel would inform the process as to
the nature of a particular claim with reference to generally accepted medical norms. A
medical expert panel would assist to expose abuses within the system, and provide
benchmarks and education for the benefit of the arbitrators and other users of the
system.
...The statutory authority for creating such a Panel already exists. The Insurance Act
allows the Minister or Superintendent to appoint a Minister’s committee to perform
whatever functions are assigned to it. Using this authority, it would be possible to
create a committee of disability and rehabilitation experts to perform a screening
function with respect to cases coming through arbitration.”
Indeed, such a panel was struck in the mid 1990’s under the Minister of Finance, but was not limited to
only “medical” experts. Following the introduction of a comprehensive first party No Fault
compensation system in 1990, and subsequent tweaks by various provincial governments since, Ontario
introduced a system of “Designated Assessment Centres” (DACs) in 1994. The DACs were administered
by a Minister’s Committee of Health Professionals along with representatives from the insurance
industry, legal profession, consumer groups and government. This Minister’s Committee was given the
mandate to oversee DACs, to develop standards and guidelines for DAC assessments, to develop fee
schedules and treatment protocols for DAC assessments, and to evaluate DAC performances. Stringent
rules were put in place to prevent potential bias and to eliminate DAC interactions with insurers or
plaintiff’s counsel, and rigid conflict of interest guidelines were introduced in order to ensure the
independence and neutrality of the DACs. Rules were established to ensure qualification of DAC
assessors. The DACs were mandated to provide assessments that were “timely, impartial,
comprehensive, and cost-effective”. The Minister’s Committee was responsible to monitor that DACs
performed within these tenets and was given responsibility to remove DACs from the DAC roster if they
did not.
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A New Auto Insurance Assessment Model
According the original description of the DAC system, still available on the FSCO website,
”Designated Assessment Centres (DACs) have been in place across Ontario for
automobile insurance companies and claimants to use when they need a neutral third-
party opinion about a claimant's injuries and the accident benefits that apply to those
injuries.
DACs are authorized to conduct independent assessments that are designed to balance
the interests of both insurance companies and claimants. Insurers are required to
initiate and pay for the cost of the assessment, and the claimant is required to
cooperate in the assessment process.
The final report of the DAC is binding, and the insurer must adjust the statutory accident
benefits to reflect the DAC findings. If a dispute still exists after the DAC assessment, the
parties may use the mediation services at the Financial Services Commission of
Ontario to try to resolve the dispute.”
Ask any of the arbitrators from FSCO’s Arbitration Unit how successful the DAC system was in the
provision of evidence based, authoritative, and comprehensive assessment of rehabilitation needs,
disability status, attendant care essentials and catastrophic impairment status when their findings came
up in dispute resolution. Over the years that this system was in place, the professionalism of the DACs
and efforts to ensure neutrality in the DACs became apparent. However, over the latter years of its
mandate, resistance to its continuing operation grew from both insurers as well as from plaintiff’s
counsel as more and more problems, both perceived and real, began to surface.
For example, insurers did not appreciate the loss of control of the costs of benefits provided to
claimants as the decisions of the DACs were binding, pending formal dispute resolution. Perhaps this
concern needs to be revisited in any new system.
Plaintiff’s lawyers were unhappy as they perceived that the DACs rejected most Treatment Plans and
most Disability claims. However, with respect to the lawyer’s concerns, two things are important to
note. Firstly, Treatment Plans and assessment of Disability requests were sent to the DACs typically after
two years post-accident. Many of those Treatment Plans were rejected by Med-Rehab DACs
because such late or passive treatment was not supported especially when it appeared that claimants
were not receiving any further benefit from the recommended treatment. Secondly, by two years after
the accident, claims for post-104 week Disability were not supported in the majority of cases that were
assessed by Disability DACs as the claimants no longer met the test of disability (which was more
stringent after 2 years post-accident). Interestingly, most claimants seen for review of Treatment Plans
or assessment of post-104 week disability had been receiving treatment up to that point and had
already been accepted as meeting the pre-104 week disability test and had been receiving disability
benefits during that time.
Two further issues surfaced and were seen to be problematic. In order to ensure the neutrality of the
DACs, insurers, who were responsible for sending the claimant to the nearest DAC, sometimes bypassed
the nearest DAC and sent claimants to selected (preferred) DACs who tended to be oriented to the
mandate of the insurers. These events went unnoticed by claimants who for the most part were
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A New Auto Insurance Assessment Model
unaware of the closest DAC rule, and by lawyers who were unable to or just did not bother to determine
if the closest DAC(s) were skipped over.
In addition, a major misperception by claimants that DACs were responsible to insurers came from the
fact that DACs were paid by insurers. This resulted in the outcome that claimants mistrusted DACs from
the outset.
We on the Minister’s committee recommended to FSCO that the nearest DAC should be selected and
monitored by FSCO and that DACs should be paid by an independent source (FSCO). Neither of these
important issues was acknowledged by FSCO and, in my opinion, contributed significantly to the
mistrust of the DAC system by the claimants it was meant to protect.
My Recommendations
Confidence in the present IME system has deteriorated to the point where disparaging articles are now
appearing in mainstream media. The present Review of Ontario’s Dispute Resolution System is a
consequence of this corrosion of confidence. It is important for the integrity of the IME system that a
new method of evaluating claimants be considered. My recommendations, below, involve for the most
part, components of already tested models, such as elements from the previous Ontario DAC system
and some fine-tuning of components from an assessment system introduced in Colorado in 1996. I
would suggest the following for your consideration:
1. The DAC system that was introduced and refined for over a decade from 1994 through
2006 was an excellent model and should be resurrected with some additional controls.
The DACs should be chosen in a manner that clearly establishes independence from
both insurers and plaintiff’s counsel. The “closest DAC” was seen to not be the best
model. Rather, the most appropriate DAC qualified to undertake the assessment of the
particular client should be the overriding concern. FSCO should have the mandate to
characterize and roster multidisciplinary assessment centres as it did the DACs.
2. A model of DAC selection can be developed as a variant of the older, more complex
“Colorado” model in which a list of five IME assessors was provided to the claimant and
ultimately a selection was made by serial elimination. I would suggest serial selection
from a list of three to five DACs be considered. In this model, the claimant chooses one
and the insurer accepts or rejects that one. If rejected, the insurer selects the next one.
The claimant then accepts or rejects that one. And so on. This method provides the
unique result that each DAC on the list will have to become identified as a “fair” DAC by
both insurers and claimants in order to be selected. This will naturally extend to the
selection by each DAC of the quality and independence of its attending expert assessors.
This system therefore is a self-adjusting one in which competition by the DAC to be
selected as a reasonable choice by both claimant and insurer becomes predominant.
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A New Auto Insurance Assessment Model
3. The DACs must be paid by a neutral body such as FSCO. Perhaps the referring party
(insurer) could submit payment to FSCO and FSCO would pay the DAC after confirming,
as a third party, the validity (cost) of the DAC invoice.
4. While there were over one hundred DACs of various sorts in the old system (disability,
med-rehab, attendant care, catastrophic impairment), I recommend a much more
streamlined population be identified. Problems with DACs in more remote regions of
the province were identified as some undertook only a few assessments per year; in my
opinion, while some provided excellent assessments, others fell short. A smaller,
dedicated group of DACs would be easier to monitor and would more easily promote in-
service collaboration with other DACs. Such successful collaboration was seen among
the seven Catastrophic Impairment DACs in the “old system” These seven “CAT DACs”
held “CAT DAC rounds” on a regular basis to exchange ideas, to improve quality and to
maintain consistency of assessments across the system.
5. A roster of Health Professionals working in the new system would need to be vetted by
FSCO, but perhaps more stringently than was done in the old DAC system as much of the
vetting in the old system was left to the individual DACs themselves. By virtue of FSCO’s
central role, costs could be monitored and controlled. A central, government monitored
system could allow for research and development of assessment models such that
Ontario could become the flagship model for independent medical evaluation of
claimants. As a benefit in the new system, “rogue” assessors whose opinions would be
seen by various parties to frequently fall outside of the norm would be “screened out”
by assessment centres vying to be chosen by insurers and claimants (see point 2 above).
In this way, a degree of “neutrality” would continue to self-manifest in the system and
could even work to rehabilitate such rogue opinions.
6. This new model would not only answer the IBC’s recommendation for a new Minister’s
“independent and unbiased medical expert panel “ but would improve on that by also
including experts from the Health Professions, the legal bar, the insurance industry and
FSCO, as was done most successfully in the previous Minister’s DAC Committee. It
would utilize evidence based improvements and safeguards that have been gleaned
from ten years’ experience coming out of the previous DAC system. It would introduce a
hybrid model that would include not only the best elements of previous the DAC system
but would utilize improvements from the Colorado model. It would instil confidence in a
failing IME system and allow buy-in from all sides.
The introduction of a comprehensive model of assessment of injured claimants for the purpose of
establishing access to reasonable and necessary benefits provided in our highly developed No-Fault
auto insurance scheme, provides a unique opportunity to clarify, refine and conclude once and for all a
comprehensive, stable, and fair first pillar in a successful dispute resolution system.
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Thank you for your consideration of my comments.
Harold Becker, PhD, MD, FCFP(C)
Adjunct Assistant Professor, Faculty of Medicine
University of Toronto
Medical Director
Omega Medical Associates
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Appendix I
Insurance Bureau of Canada |
Submissions for Proposed Reform to FSCO ADR Process
September 20, 2013
http://www.fin.gov.on.ca/en/consultations/pension/submissions/odrsrs/Insurance%20Bureau%
20of%20Canada%20%28IBC%29%20-%20DRS%20Review%20submission%20-
%20September%202013.pdf
Recommendation 2:
Creation of a Medical Expert Panel
Currently arbitrators do not have access to a neutral benchmark for the generally expected
medical course for claims under the SABS. We propose engagement of an independent and
unbiased medical expert panel, mandated to provide insight on the evidence -based state of
medical knowledge. The panel would inform the process as to the nature of a particular claim
with reference to generally accepted medical norms. A medical expert panel would assist to
expose abuses within the system, and provide benchmarks and education for the benefit of the
arbitrators and other users of the system.
A.
Statutory Authority for Creating a Medical Expert Panel
The statutory authority for creating such a Panel already exists. The Insurance Act allows the
Minister or Superintendent to appoint a Minister’s committee to perform whatever functions
are assigned to it. Using this authority, it would be possible to create a committee of disability
and rehabilitation experts to perform a screening function with respect to cases coming through
arbitration.
B.
Role of the Medical Expert Panel
The role of the medical panel would be to conduct a paper review of the particular claim for
healthcare and disability costs, and to provide a report simply to set out the parameters of the
expected norms typically associated with the claim, founded on medically-based evidence. The
report would not prejudge the outcome, but would set the context for evaluating the claim on
its merits. In particular, the report would establish the following:
 Whether the type of impairment diagnosed is a common diagnosis,
 Whether the disability alleged in relation to the impairment is the kind of
disability, both in terms of character and duration, normally encountered for
this diagnosis of injury,
 What the normal modalities of treatment are for such injuries, as well as the
frequency and cost of the treatment based upon similar claims grounded in
evidence based medicine,
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

Whether the diagnosis is one normally made after an event such as the
accident In question, and
Additional comments on the treatment offered and claimed.
The report would provide an anchor or benchmark regarding the generally expected medical
course for a kind of case. The arbitrator would then be in a better position to understand the
assertions made by the parties, and determine whether evidence justifying the claim is required.
Arbitrators would more easily recognize allegations that are outside of medical norms, and
would accordingly be in a position to require cogent and convincing evidence to sustain the
allegations.
The panel would also play an important role in assist with the elimination of abuses. For
instance, it could be part of the panel's role to report issues of competence and dishonesty to
the appropriate medical college. The panel could also make referral to investigators who might
be charged with looking at any portrayed improprieties, promoting compliance with the SABS.
Reporting such issues would result in a repository of intelligence identifying the players in t
he system that appear to be repeatedly engaging in questionable practices. As indicated above,
the involvement of the panel would be strictly limited to providing background for the arbitrator
not to provide a judgment or assessment with respect to any of the actual entitlement issues.
Furthermore, the panel would not be tasked with reviewing lengthy volumes of medical
documentation for the purpose of preparing the report. Rather, brief summaries concerning the
claimant’s condition and course of treatment would suffice for this purpose, which would
reduce the time and expense associated with this role.
C.
Qualifications of the Medical Expert Panel
As part of their role, the panel would be obligated to provide comments on the particular claim
based on generally -accepted medical and scientific principles. In terms of who would qualify to
be on the panel, panel members would ideally be nominated by their respective regulatory
college, and be members or designates of their respective quality assurance committees
D.
Advantages of the Medical Expert Panel
There are a number of advantages to making use of the existing statutory authority to create a
medical expert panel. Those advantages include the following:




Neutral expertise is brought to each case, at a relatively low cost,
A benchmark is created for the evaluation of entitlement in each case,
The system users will become more educated about mainstream medical
science and generally-accepted norms for the course of claims, and
Abusers of the system will be identified and appropriately reported by the
panel members.
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Appendix II
The “Colorado Assessment Model”
http://tinyurl.com/Appendix-II)
(http://www.state.co.us/gov_dir/leg_dir/olls/digest1996/INSURANCE.htm#96-078)
Session Laws of Colorado 1996
Second Regular Session, 60th General Assembly
CHAPTER 146 SENATE
BILL 96-078
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Appendix III
Division of Insurance 3 CCR 702-5 AMENDED REGULATION 5-2-9
PERSONAL INJURY PROTECTION EXAMINATION PROGRAM
http://tinyurl.com/Appendix-III
AT PAGE 35 - this is a large document:
“Pip Examination Program: Effective January 1, 1997: Effective January 1, 1997, Colorado
restricts the ability of PIP carriers to select IME examiners. The PIP examination program is the
exclusive method for obtaining an independent medical examination from a health care
practitioner other than a treating provider relating to a disputed PIP claim.
The PIP examination program is conducted under the supervision of the Colorado Commissioner
of Insurance, which is to provide a group of licensed health care practitioners to serve as the PIP
examination review panel. A health care practitioner participating in the PIP review panel shall
be actively engaged in the practice of his or her profession and the majority of such practice and
income shall not derive from witness fees and examination of persons not under the
practitioner’s care and treatment. It shall be the duty of the PIP examination review panel to
perform the PIP examinations at the request of the commissioner. See C.R.S. § 10-4-706(6)(b).
Any insurer, insured, or injured person entitled to benefits has the right to obtain a PIP
examination with the health care practitioner from the PIP examination review panel regarding
each type of treatment involved in the disputed portion of the PIP claim. When submitting the
request for a PIP examination, the requesting party shall specify the professional specialty of the
health care practitioner who will perform the PIP examination. Where practical, such
professional specialty shall be the same as that of the treating health care practitioner whose
treatment and opinion are intended to be reviewed by the member of the PIP review panel;
except that psychiatrists, psychologists and neuropsychologists may review one another’s
treatment and opinions to the extent that the reviewing expert is qualified to address the
specific issues which arise in a particular case. Nothing in this section should preclude a
managed care organization from using its usual and customary review procedures. See C.R.S. §
10-4-706(6)(c).
Though a revolving selection process established by rule, the commissioner shall prepare a list of
five health care practitioners qualified to perform the PIP examination, and submit it to the
requesting party. Within five days of receipt, the requesting party shall strike two names from
the first list and submit it to the opposing party. Within five days of receipt, the opposing party
shall strike two names from the list. The opposing party shall immediately return the list to the
commissioner. The insurer and insured or the injured person entitled to benefits may agree
upon a health care practitioner to perform the PIP examination without using the revolving
selection process. Upon the selection of the health care practitioner, the PIP examination shall
proceed and the requesting party shall pay the cost of the examination. See C.R.S. § 10-4-
706(6)(d).
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The PIP health care practitioner shall determine whether the treatment that has been rendered
to the insured or injured person entitled to the benefits is reasonable, necessary, and if such
claimed injury or condition arises out of the use of a motor vehicle. See C.R.S. § 10-4-706(6)(e).
A health care practitioner who performs a PIP examination pursuant to this subsection shall be
immune from civil liability in any action brought by any person based upon such practitioners
findings, opinions and conclusions, absent a showing of malice or bad faith on the part of the
examining health care practitioner. See C.R.S. § 10-4-706(6)(f).
In the event the findings, opinions and conclusions of the PIP review panel member are contrary
to the statement of causation, diagnosis, prognosis, plan of treatment, opinions, or
recommendations of the treating practitioner whose actions have been reviewed, any party
dissatisfied with such findings, opinions and conclusions may seek and pay for a second PIP
examination under the procedures set forth in paragraph (c) and (d) of this subsection. See
C.R.S. § 10-4-706(6)(g).
In any arbitration or judicial proceeding commenced by the insurer, insured or injured person
entitled to benefits, the findings, opinions, and conclusions of the PIP examination shall be
presumed to be correct, but such presumption may be rebutted by a preponderance of the
evidence. If there has been a second PIP examination pursuant to paragraph (g) of this
subsection, the agreed upon findings, opinions, and conclusions of two of three health care
practitioners shall be binding unless rebutted by clear and convincing evidence in any arbitration
or judicial proceeding commenced by the insurer, the insured, or the injured person entitled to
benefits. No civil proceeding, including but not limited to, a proceeding alleging any cause of
action under section 10-4-708 or the tort of bad faith breach of the insurance contract, arising
out of any action taken by the insurer that is consistent with the agreed upon findings, opinions,
and conclusions of two of three health care practitioners shall be brought or maintained against
the insurer; except that the insured or injured person entitled to benefits may bring a civil
proceeding alleging that clear and convincing evidence rebuts the findings, opinions, and
conclusions of the two of the three health care practitioners.
If the insured or injured person entitled to benefits is successful, the no-fault insurer shall be
obligated to pay the no-fault benefits that have been denied and that were the subject of such
proceeding. See C.R.S. § 10-4-706(6)(h).
Releases: If there is both liability and a PIP claim, the release must specifically refer to releasing
the PIP claim. See Cingoranelli v. St. Paul Fire and Marine Ins. Co., 658 P.2d 863 (Colo. 1983).
In Colorado, third parties do not have a right of direct action against an opposing party's
insurance carrier. Therefore, there is no need for the insurer to be listed on releases executed
by third parties...”
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