answers to some of the tough questions that insurers get asked in Ontario. We hope it helps you own the road this summer.

Transcription

1 Dear colleague, We ve prepared this Q&A backgrounder to arm you with answers to some of the tough questions that insurers get asked in Ontario. We hope it helps you own the road this summer. We ll follow up soon with more Q&As as they become available. Please keep your questions and comments coming. Your input is invaluable as we embark on this new consumer education campaign. Best regards, Ralph Palumbo Vice-President, Ontario Insurance Bureau of Canada.

2 1. Why is government looking to change the definition of the catastrophic impairment (CAT) designation? 2. How will the new CAT definition be an improvement? Could you respond to these tough consumer questions? 3. Will changing the definition reduce the number of eligible claimants as some medical practitioners and lawyers suggest? 4. Medical and rehab providers also say that insurers are restricting injury claimants access to care for all types of injuries by denying assessment and treatment claims and reducing benefit payments. Is this true? 5. Why do insurers use territory or where a driver lives to help determine his or her insurance rate? 6. Why are some rates going up or staying the same? Shouldn t they be going down? 7. Some critics argue the insurance industry s earnings are too high. What is the industry response?

3 Here are the right answers 1. Why is government looking to change the definition of the catastrophic impairment (CAT) designation? The CAT designation is a legal term to define severe medical conditions resulting from auto collision injury. The designation gives eligible claimants the right to receive much higher benefits than other injury claimants to ensure that the most seriously injured people who are not able to sue an at-fault driver have enough resources for the care they need. The current definition of the CAT designation is several decades old and doesn t take into account medical advances in determining impairment. KEY POINTS The current definition is outdated and doesn t reflect medical advances in determining impairment. The current definition is open to legal dispute, which delays resolving claims and adds costs. An updated definition would ensure that claimants receive fair and timely benefits. As well, over time, arbitrators and the courts have applied the CAT designation inconsistently, resulting in uncertainty around its proper application and therefore costly legal disputes that take a long time to resolve. Finally, while injuries from collisions have steadily declined, the number of CAT designation injuries reported to insurers has increased rapidly, which further suggests the CAT designation is not being applied fairly. It s time to revisit how the CAT designation is defined to make it more consistent and fair. This will ensure that eligible claimants receive the benefits associated with the CAT designation in a timely fashion.

4 2. How will the new definition of CAT designation be an improvement? Under the new definition, the level of impairment caused by an injury and whether someone qualifies for a CAT designation would be determined based on a person s ability to perform everyday activities including his or her normal job as measured by current scientifically-proven tests to assess impairment. KEY POINT The new definition is fairer because it uses scientifically proven tests to measure impairment. Further, in some cases of brain injury, the injured person must have been admitted for in-patient rehabilitation in a public health care facility. Use of hospital admission as a criterion acknowledges the public health system s expertise in determining appropriate levels of care. It also removes the financial incentive for claimants, their families, private sector health care providers and lawyers to assume a role in determining impairment. 3. Will changing the definition reduce the number of claimants qualifying for CAT designation as some medical practitioners and lawyers suggest? KEY POINT Only time will tell whether the new definition affects the number of CAT designations. It is too early to know whether the number of CAT designations will go up or down. What we do know is that the new definition will be applied in a more uniform sciencebased way by specially-trained health professionals. This will result in more consistent and timely decisions and fewer costly legal disputes.

5 4. Medical and rehab providers also say that insurers are restricting injury claimants access to care for all types of injuries by denying assessment and treatment claims and reducing benefit payments. Is this true? No, it s not true. What is true is that we have seen a drop in the cost of no fault injury payments. What that tells us is the September 2010 reforms are working as intended to reduce excess cost, fraud and abuse in the system. KEY POINTS The drop in the number of no-fault claims payouts shows the auto reforms are working. The claims payouts before reforms were too high because of fraud and abuse so it was inevitable that some claims would be denied or reduced. Adjusters don t make medical decisions. When in doubt, they send files for review by independent medical examiners. Here s a reminder of why the reforms were needed. Between 2006 and 2010 the number of collisions in Ontario dropped by 7% but the cost of no fault injury benefits rose by 118%. Much of that increase is a result of fraud and abuse. To reduce this strain on the system, unjustified healthcare providers assessment and treatment proposals and corresponding claims payouts had to be denied. Let s look at the numbers another way. There are 62,000 collision injuries in Ontario every year, of which most are minor strains, sprains and whiplash. More than 8,600 health care facilities are enrolled in the provincial online billing system to provide services to these injury victims. And every month, these providers submit 27,000 treatment and assessment proposals to insurers. So if we do the math for a year, 62,000 injuries, which are mostly minor, are generating 324,000 treatment and assessment proposals on an annual basis. That s 5.2 proposals per claimant.

6 Given those numbers, it should come as no surprise that some treatment and assessment proposals are not accepted, and many must be modified before insurers will accept them. That being said, insurance adjusters don t make medical decisions. Their job is to assess whether treatment and assessment proposals follow government guidelines. When an adjuster has doubts about the medical judgment on which a proposal is based, he or she sends the file to an independent medical examiner for review. 5. Why do insurers use territory or where a driver lives to help determine his or her insurance rate? First of all, using territory as a rating factor is not unfair. Territory has been proven through actuarial analysis to be a good predictor of insurance losses. For example, using 2011 statistics, the average claims cost per vehicle in Brampton was $2,667, which was more than 25% higher than in Toronto and 40% higher than in Mississauga. Of course there are good drivers in Brampton just as there are poor drivers in Toronto and Mississauga. But the numbers show that, on average, Brampton drivers have a much poorer claims record than Toronto or Mississauga drivers. We don t know why this is but we do know it s a fact. If insurers were not allowed to use territory as a rating factor, drivers in areas with better claims records would pay more and drivers in areas with poorer claims records would pay less. This would certainly be unfair.

7 KEY POINTS Territory is a fair rating factor and a good predictor of insurance losses. We don t know why some regions have higher average claims costs than others but we know that there is indeed a difference in claims experiences. Territory is only one of many rating factors. However, territory is only one of many rating factors, along with the age and model of the vehicle, age and gender of driver, number of traffic violations and at-fault accidents, etc. And as one of many risk factors, territory is not the prime determinant of someone s premium cost. To show this, IBC did a premium comparison using two driving profiles from the city of Brampton. The profiles were identical same driver age, gender, type of vehicle, use of vehicle, etc. The only difference was that one driver had a clean driving record and the other driver had two at-fault collisions and a speeding ticket in the previous six years. The average premium available to the second driver was double that of the first driver. 6. Why are some rates going up or staying the same? Shouldn t they be going down? Despite the 2010 reforms, insurers still lost $1.76 billion on Ontario auto in And it will take time to remove abuse and fraud from the system. Every few weeks, we hear about another fraud ring or shady rehab clinic scamming the system. As well, there are 35,000 claims currently in mediation with these claimants, their healthcare providers and lawyers still hoping the 2010 reforms will be reversed by arbitrators or the courts. If they re right and the intent of the reforms is not upheld, then insurers will be required to pay larger claims; they must keep money in reserve for this possibility.

8 KEY POINT Many factors affect premiums including fraud and abuse of the system, which will take time to eliminate. Finally, while Ontario is a no-fault system, it does have an at-fault component that allows people with serious injuries to sue an at-fault driver for compensation above their no-fault benefits. The number of suits is increasing and the settlements are getting bigger. 7. Some critics argue the insurance industry s profits are too high. What is the industry response? In spite of what has been reported in the press recently, it is not true that insurance companies have a guaranteed 12% profit. KEY POINTS Insurance company profits are moderate. The industrywide return on equity ranged from 6% in 2008 to 8% in In 2011, mining had an ROE of 9.8% by comparison. Between 2008 and 2010, insurers lost $2.96 billion on Ontario auto. In 2011, the industry-wide return on equity (ROE) was 8%. In the same year, mining had an ROE of 9.8%, manufacturing was at 10.6% and retail at 11.8%. And if we look back a few years, insurance ROE has been moderate. It was 7.6% in 2010, 6.9% in 2009 and 6% in Although premiums may have risen, insurer profits are definitely not the reason. In fact, between 2008 and 2010, the industry lost a total of $2.96 billion on Ontario auto. It is also important to remember that all auto insurance rates in the province must be approved by the government regulator, the Financial Services Commission of Ontario.