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Despite COVID-19 guidelines, insurers still deny attendant care claims | Joseph Campisi

On June 3, more than two months after Ontario declared a state of emergency, the Financial Services Regulatory Authority of Ontario (FSRA) released an Interpretation titled: “Statutory Accident Benefits Claims during the COVID-19 Outbreak.” Its declared purpose is “to provide FSRA’s Interpretation of the requirements of subsections 1(9), 3(2)5 and 6(1) of O. Reg. 7/00 — Unfair or Deceptive Acts or Practices under the Insurance Act” in the context of statutory accident benefits (SABs) claims during the COVID-19 crisis.

These subsections set out the following as unfair or deceptive acts or practices:

        • 1(9). Any conduct resulting in unreasonable delay in, or resistance to, the fair adjustment and settlement of claims.
        • 3(2)5. Charging an amount in consideration for the provision of goods or services to or for the benefit of a person who claims statutory accident benefits or who otherwise claims payment under a contract of insurance, where the amount charged unreasonably exceeds the amount charged to other persons for similar goods or services.
        • 6(1) The failure or refusal of an insurer without reasonable cause to pay a claim for goods or services or for the cost of an assessment within the time prescribed for payment in the Schedule.

In recognition of the additional challenges and complexities facing SABs claimants — such as communicating with adjusters, providing paperwork, attending treatment and assessments and receiving in-home support — the FSRA issued this guidance to announce its intention to use the regulatory tools at its disposal to ensure that claimants are treated fairly during the pandemic.

This guidance is in keeping with the statutory mandates of the FSRA:

  • to contribute to public confidence in the insurance sector;
  • to protect the rights and interests of insurance consumers;
  • to deter deceptive or fraudulent conduct, practices or activities by the insurance sector; and
  • to promote high standards of business conduct in the insurance sector.

FSRA’s release of this document highlights the use of unfair or deceptive acts or practices by the insurance industry relating to accident benefits claims in the first months of the crisis, despite website slogans of insurers, like: “Working together to deal with COVID-19” and “We believe that insurance is about people. Our priority is to be there for customers and brokers when they need us.”

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