Medical files ‘routinely altered’ to suit insurers, claims FAIR

by Donald Horne | 29 Dec 2014

 Auto accident victim medical files are “routinely being altered to suit Ontario’s insurers need to save money,” says the board chair of FAIR.

In a scathing letter sent to Ontario MPPs, Rhona DesRoches – the chair of the fair association of victims for accident insurance reform (FAIR) – cites leaked documents from a discussion forum as evidence that “portions of medical reports have been removed, manipulated or even changed entirely without the author’s knowledge or consent in order to minimize victim injuries.”

DesRoches goes on to claim that “signatures have been forged or used without permission in many cases,” done to “misled our justice system and to lower claims costs.”

One document in question – provided to Insurance Business by DesRoches – is testimony from Maia L. Bent, a partner at the law firm of Lerners in London, Ont.

In it, Bent states that:

“I am involved in an Arbitration on the issue of catastrophic impairment where Sibley aka SLR Assessments did the multi-disciplinary assessments for TD Insurance. Last Thursday, under cross-examination the IE neurologist, Dr. King, testified that large and critically important sections of the report he submitted to Sibley had been removed without his knowledge or consent. The sections were very favourable to our client. He never saw the final version of his report which was sent to us and he never signed off on it.
 
“He also testified that he never participated in any ‘consensus meeting’ and he never was shown or agreed to the Executive Summary, prepared by Dr. Platnick, which was signed by Dr. Platnick as being the consensus of the entire team.
 
“This was NOT the only report that had been altered. We obtained copies of all the doctor’s file and drafts and there was a paper trail from Sibley where they rewrote the doctors’ reports to change their conclusion from our client having a catastrophic impairment to our client not having a catastrophic impairment.”

Bent continues that:

“This was all produced before the arbitration but for some reason the other lawyer didn’t appear to know what was in the file (there were thousands of pages produced). He must have received instructions from the insurance company to shut it down at all costs on Thursday night because it offered an obscene amount of money to settle, which our client accepted.
 
“I am disappointed that this conduct was not made public by way of a decision but I wanted to alert you, my colleagues, to always get the assessor’s and Sibley’s files. This is not an isolated example as I had another file where Dr. Platnick changed the doctor’s decision from a marked to a moderate impairment.”

For DesRoches, it is just another example of the controversy surrounding how claims are handled in Ontario.

“Claimants have long known about the shady and unacceptable deceptive nature of claims handling in Ontario,” she said. “It’s time that our legislators and law-makers acknowledge Ontario’s insurance company fraud, whether it be an adjuster, an assessor, assessment centers, treatment facility or the insurer themselves whose policies support or encourage swindling legitimate claimants out of the coverage they paid for.”

She goes on to ask politicians to step up and make good on their promises to fight fraud in the insurance system – all fraud.

“Is this what the fight on fraud is all about – just a one-sided attack on claimants?” asks DesRoches. “When a (FSCO senior arbitrator) lays it out there that ‘State Farm accepted the opinions of its medical advisors to support its routine denials of benefits’ isn't it time to acknowledge that the word ‘routine’ means insurer fraud is happening on a daily basis and harming legitimately injured MVA victims?”

DesRoches' State Farm example comes from the findings of a trier-of-fact: Jazey and State Farm (Jazey and State Farm  [+] Arbitration, 2014-12-09, Reg 403/96. Final Decision FSCO 4330)

To read the entire FSCO report, see SIDEBAR: ‘Jazey and State Farm’

For DesRoches, it is a simple matter of creating laws that protect the consumer from unacceptable business practices that cause harm.

“Accident victims deserve better and we depend on our courts for justice when insurers behave badly,” she said. “Ontario’s consumers expect our legislators to act in the best interests of the people of Ontario and we look to you to enact legislation that protects consumers from fraud.”

According to Aisha Silim at FSCO, the Jazey/State Farm has been appealed.

Source: http://www.insurancebusiness.ca/news/medical-files-routinely-altered-to-suit-insurers-claims-fair-186692.aspx?p=2