Closed Automobile Insurance Third Party Liability Claim Study in Ontario

Transcription

1 Closed Automobile Insurance Third Party Liability Claim Study in Ontario Survey Completion Instructions 1. Please complete one record for each injured claimant resulting from the same accident. For example, if an accident gives rise to three injured claimants, three separate forms have to be completed. a. Regarding Family Law Act Claims, in the event of one injured claimant and multiple resulting FLA claims, fill out one form only. 2. Survey should be completed only for claims with indemnity payments (payments to claimants). 3. Each company will be given a target number of claims and a list of claim numbers to be included in the sample. Companies will be provided with approximately 50% more claim numbers than the target number of claims. 4. If the claim for a given ID cannot be found due to wrong ID, claim files missing, claims closed without payment, etc. this ID should be skipped. 5. If more than one relevant coverage (i.e. Bodily Injury, OPCF 44R) is involved in the claim occurrence, complete one survey response for each Bodily Injury claimant for each such coverage involved in each claim occurrence. 6. Records can be completed either directly in the table or by using the form in the provided Excel file. a. If inputting or copying data into the ClaimsData sheet in Excel, the paste value approach should be used to preserve formatting used for data validation. 7. All fields must be completed. Using the form will result in needing to fill in fewer actual answers given that some answers will be determined based on answers to other questions. If answers are entered directly into the Excel spreadsheet table, each cell will need to be filled in. 8. Please include requested amounts rounded to the nearest dollar. 9. Please ensure that amounts that should balance to the answers of other questions do balance. 10. All settlement amounts are to be shown gross of reinsurance recoveries, if any. Where breakdowns of settlement amounts by heads of damage are required, these should be obtained from the award in the judgment in the case, after reduction for contributory negligence, if any. If no such award exists (i.e. pre-trial settlement), then these breakdowns should be estimated in a reasonable fashion by a claims expert. One way to do this might be to take the latest settlement offer produced by the claimant's legal counsel (when relevant), drop any heads of damage which the insurer thinks to be unreasonable, and prorate the actual settlement amount in proportion to the remaining heads of damage in the offer. 11. All claimant demographic information should be provided as of the date of the accident. 1 P age

2 12. Each claimant should be interpreted as each injured person, regardless of who is actually claiming damages (e.g. Family Law Act Claims). 13. For each injury category, check the boxes for all applicable injuries. For neck and back injuries, select the category (minor, moderate, or severe) related to the most serious medical injury in that category based on your professional judgment. 14. All dates should be completed in YYYYMMDD format. 15. All percentages should be entered as a whole number sample claims should be completed and returned within two weeks of receiving this package. a. The sample responses will be reviewed and the results of this review will be communicated to each company. b. If, as a result of the training or the sample, clarifications to the instructions need to be made, this will be completed within one week of receiving the sample claim survey responses. 17. Completed surveys as of the end of each week should be forwarded to Pinnacle for review. 18. Company should continue the report until the target number of claims is reached. If you have any questions as you are completing the survey, please contact Roosevelt Mosley or Nick Kucera. Roosevelt Mosley (309) [email protected] Nick Kucera (630) [email protected] 2 P age

3 Survey Questions Claim Information 1. Company Number 2. Initials of Person Completing the Form 3. Claim Number 4. Claimant Number 5. Policy Number 6. Claim Type 1 = Bodily Injury (Includes uninsured motorist and unidentified motorist) 2 = OPCF 44R 7. What was the actual policy limit of the applicable coverage? 8. What was the GISA Statistical Territory Code of your insured vehicle? 9. What was the GISA Type of Use Code of your insured vehicle? 3 P age

4 Accident Information 10. What was the claimant s role in the accident? 1 = Driver of other than your insured s vehicle 2 = Passenger in other than your insured s vehicle 3 = Named insured driver 4 = Named insured passenger in insured's vehicle 5 = Passenger (not named insured) in insured's vehicle 6 = Pedestrian 7 = Motorcycle driver 8 = Motorcycle passenger 9 = Other 10 = Unknown 11. What was the gender of the claimant? 1 = Male 2 = Female 3 = Unknown 12. What was the date of birth of the claimant or age of the claimant at the time of the accident? 13. Was the claimant an adult or a dependent child? 1 = Adult 2 = Dependent child 14. What was the marital status of the claimant at the time of the accident? 1 = Married 2 = Single 3 = Widowed 4 = Divorced/Separated 5 = Unknown 15. How many vehicles were involved in the accident? 16. What type of vehicle was the claimant driving? 1 = Car 2 = Truck 3 = Van 4 = Motorcycle 5 = Bus 6 = Snow vehicle 7 = ATV 8 = None (passenger, pedestrian, bicyclist) 9 = Unknown 4 P age

5 17. What type of vehicle was the insured driving? 1 = Car 2 = Truck 3 = Van 4 = Motorcycle 5 = Bus 6 = Snow vehicle 7 = ATV 8 = Unknown 18. What was the insured s degree of fault? % 19. What was the claimant s degree of fault? % 20. Where did the accident occur? 1 = Ontario 2 = Québec 3 = Other jurisdiction in Canada 4 = U.S.A 21. What was the date of the accident? (YYYYMMDD) 5 P age

6 22. What time did the accident occur? 1 = 12:00 AM 2 = 1:00 AM 3 = 2:00 AM 4 = 3:00 AM 5 = 4:00 AM 6 = 5:00 AM 7 = 6:00 AM 8 = 7:00 AM 9 = 8:00 AM 10 = 9:00 AM 11 = 10:00 AM 12 = 11:00 AM 13 = 12:00 PM 14 = 1:00 PM 15 = 2:00 PM 16 = 3:00 PM 17 = 4:00 PM 18 = 5:00 PM 19 = 6:00 PM 20 = 7:00 PM 21 = 8:00 PM 22 = 9:00 PM 23 = 10:00 PM 24 = 11:00 PM 25 = Unknown 23. How was the accident classified according to the police report? 1 = Fatal injury 2 = Non-fatal injury 3 = PD only 4 = Non-reportable 5 = Other 6 = No Police Report 24. What was the description of the injuries according to the police report? 1 = None 2 = Minimal 3 = Minor 4 = Major 5 = Fatal 6 = No Police Report 6 P age

7 Claim Settlement Information 25. Accident Report Date What date did the insured report the accident to your company? (YYYYMMDD or N/A if not applicable) What date did an injured third party or their legal representative report the accident to your company? (YYYYMMDD or N/A if not applicable) 26. On what date was a bodily injury reserve opened? (YYYYMMDD) 27. Who made the first verbal or written offer to settle? 1 = Claimant 2 = Claimant s legal representative 3 = Your company 4 = Neither 5 = Unknown 28. What was the date of first verbal or written offer to settle? (YYYYMMDD) 29. What was the date of the first indemnity payment made to the claimant? (If there is only one payment made to the claimant, consider it the first and final/full payment for this question.) (YYYYMMDD) 30. What was the amount of the first indemnity payment made to the claimant? (If there is only one payment made to the claimant, consider it the first and final/full payment for this question.) 31. What was the amount of the initial best estimate case reserve established for the claimant? 32. Prior to settlement, was there a risk of exposing the policyholder to liability in excess of coverage (based off of actual realistic assessment or best judgement rather than a legal representative s pleadings/or statement of claim amount)? 1 = Yes 2 = No 3 = Unknown 33. Was the SABS insurer involved in concurrent settlement negotiations? 1 = Yes 2 = No 3 = Unknown 7 P age

8 34. What was the date that the BI claim for this specific claimant was closed? (This is the final closing date in cases where the file was reopened.) (YYYYMMDD) If the claim is still open, what is the estimated outstanding remaining dollar liability for the claim? Claimant Employment Information 35. What was the employment status of the claimant at the time of the accident? 1 = Employed full time 2 = Employed part time 3 = Homemaker 1 4 = Student 5 = Pre-school age 6 = Retired 7 = Unemployed 8 = Other 9 = Unknown 36. What type of employment was the claimant involved in at the time of the accident? 1 = Managerial/professional 2 = Clerical 3 = Manual 4 = Self-employed 5 = None 37. What was the gross weekly income of the claimant at the time of the accident? (If unemployed, enter 0.) 38. How much time did the claimant lose from work from the injury to the date of the settlement? (If less than one month provide the number of days, if greater than one month provide the number of months) (Please specify if days or months) 39. Was loss of competitive advantage claimed by the claimant? 1 = Yes 2 = No 3 = Unknown 1 A person who manages a household as one s main daily activity 8 P age

9 Injury Information 40. What date was the injury reported to your company? (YYYYMMDD) 41. Who first reported the injury to the insurer? 1 = Insured 2 = Claimant 3 = Claimant s legal representative 4 = Other 5 = Unknown 42. What was the condition of the claimant as a result of the accident? 1 = Fatality (at the scene of the accident) 2 = Injured 3 = Not Injured 43. Type of injury claimed (Select all that apply.) No injury Death Psychological impairment o Anxiety o Depression o Post Traumatic Stress Disorder (PTSD) Mental impairment Quadriplegia, Paraplegia, Hemiplegia, or other spinal injury Head Face o Permanent brain injury o Concussion o Post-Concussion Syndrome o Scalp Avulsion/Laceration Head/Brain Injury o Laceration with scar o Laceration with no scar o Jaw Fracture o Loss of Teeth o Temporomandibular Joint Dysfunction (TMJ) o Tooth/Jaw Other Injury 9 P age

10 Neck Back o Mild strain, sprain or soft tissue injury o Moderate strain, sprain or soft tissue injury o Severe strain, sprain or soft tissue injury o Mild strain, sprain or soft tissue injury o Moderate strain, sprain or soft tissue injury o Severe strain, sprain or soft tissue injury Chest and Ribs Internal o Internal organ injury where surgery was required Shoulder o Strain/Soft tissue o Laceration Arm o Loss of one arm o Loss of both arms o Laceration arm injury Elbow Wrist and Hand of Wrist or Hand o Loss of one hand o Loss of both hands o Laceration of wrist or hands o Loss of fingers o Strain of the wrist or finger wrist or hand injury Pelvis and Hip 10 P age

11 Leg Knee o Loss of one leg o Loss of both legs o Laceration leg injury o Soft Tissue/Sprain/Strain Ankle and Foot of ankle or foot o Loss of one foot o Loss of both feet o Sprain o Laceration of ankle or foot ankle or foot injury Burns Fibromyalgia Chronic pain Subluxation Permanent loss of a sense (taste, smell, sight, touch or hearing) Other disfigurement Other Injury 44. Among those injuries checked, indicate which, in your judgment, was the most serious injury? 45. Which injury was the most expensive? (Medical treatment costs) 11 P age

12 Claim Payment Information 46. What are the total amounts of gross payments made to the claimant? 47. What were the punitive damages awarded? 48. Breakdown of all loss amounts, including claim payments, settlement amounts and trial awards. Special damages o Loss of Income (net of collateral sources): income loss (net of collateral sources): o Medical & rehabilitation (net of collateral sources): o Housekeeping: o Family Law Act: o Funeral expenses: : o Subtotal: General damages o Non-pecuniary: o Family Law Act: o Loss of future employment income: o Future care: o Gross up for tax: o Fund management (to handle settlement amount): o Subtotal: Partial Indemnity Cost (Party and party): Prejudgment interest: Disbursements: 49. Was the non-pecuniary deductible applied? 1 = Yes 2 = No 12 P age

13 50. Family Law Act Claims (if FLA payment was paid as a lump sum, allocate to individual categories using your best judgment): Amount paid to spouse: o Deductible Applied (Yes/No): Children o Number of claimants: o Number of claimants paid: o Amount paid: o Deductible Applied (Yes/No): Grandchildren o Number of claimants: o Number of claimants paid: o Amount paid: o Deductible Applied (Yes/No): Parents o Number of claimants: o Number of claimants paid: o Amount paid: o Deductible Applied (Yes/No): Grandparents o Number of claimants: o Number of claimants paid: o Amount paid: o Deductible Applied (Yes/No): Siblings o Number of claimants: o Number of claimants paid: o Amount paid: o Deductible Applied (Yes/No): Other o Number of claimants: o Number of claimants paid: o Amount paid: o Deductible Applied (Yes/No): 51. Breakdown of Internal/External Expenses Insurer s outside counsel: Insurer s in-house counsel: Independent adjuster: Defence medical: Other expert (i.e. private investigators, surveillance, accident reconstruction): Other claim expenses (i.e. court reports, police reports, other costs that can be allocated to the claim): 13 P age

14 52. Were Statutory Accident Benefits paid? 1 = Yes 2 = No 3 = Unknown 53. Has the claimant been determined to be catastrophically impaired for the purposes of the accident benefits coverage? 1 = Yes 2 = No 3 = Unknown 54. Was a future care plan submitted by the claimant? 1 = Yes 2 = No 3 = Unknown 55. Amount of Statutory Accident Benefits paid: Medical: Rehabilitation: Attendant Care: Caregiver: Funeral: Death: Housekeeping and Home Maintenance: Income replacement: Dependant care: Non-earner: Education: Other: Total: Total deducted from BI payment: 56. Were salary continuance benefits paid by the employer? 1 = Yes 2 = No 3 = Unknown 57. Amount of salary continuance benefits paid by employer: Percentage of salary paid under sick leave: Amount of salary paid under sick leave: Percentage of salary paid under short term disability: Amount of salary paid under short term disability: Percentage of salary paid under long term disability: Amount of salary paid under long term disability: Total: Total deducted from BI payment: 14 P age

15 58. Were government benefits received by claimant (EI, CPP, Worker's compensation, or other)? 1 = Yes 2 = No 3 = Unknown 59. Amount of government benefits paid: EI: CPP: Worker s compensation: Other: Total: Total deducted from BI Payment: Claim Process Information 60. When was the first medical report received by your company? (YYYYMMDD) 61. Did the claimant have legal representation? 1 = Yes 2 = No 3 = Unknown 62. Was a legal action commenced? 1 = Yes 2 = No 3 = Unknown 63. Was the claimant examined for discovery? 1 = Yes 2 = No 3 = Unknown 64. Was the case pre-tried? 1 = Yes 2 = No 3 = Unknown 65. Did the case go to trial? 1 = Yes 2 = No 66. Was the case tried by a jury? 1 = Yes 2 = No 3 = Unknown 15 P age

16 67. What was the net verdict or net settlement amount compared to the last settlement offer or last demand (whichever came last)? 1 = Less than last offer 2 = Equal to last offer 3 = Larger than last offer 4 = Less than last demand 5 = Equal to last demand 6 = Larger than last demand 7 = No settlement offer or demand 8 = Unknown 68. Was there an appeal? 1 = Yes 2 = No 3 = Unknown 69. If appealed, was the case appealed by the plaintiff? 1 = Yes 2 = No 3 = No appeal 70. Was the case settled? If so, when? 1 = Before legal action commenced 2 = After legal action commenced but before examination discovery 3 = After examination for discovery but before pre-trial 4 = At pre-trial or as an immediate consequence of pre-trial 5 = Between pre-trial and date action called for trial 6 = At trial 7 = Not settled 71. Was an independent medical exam conducted? 1 = Yes 2 = No 3 = Unknown 72. Was the independent medical exam conducted before or after legal action commenced? 1 = Before legal action commenced 2 = After legal action commenced 3 = No independent medical exam conducted 73. Did your company require a statement under oath from the claimant? 1 = Yes 2 = No 3 = Unknown 16 P age

17 74. Was the claim paid under a structured settlement? 1 = Yes 2 = No 3 = Unknown 75. Was the structured settlement entered into voluntarily or required by the court? 1 = Voluntarily 2 = Required by court 3 = No structured settlement 4 = Unknown 76. Other than Partial Indemnity Cost (Party and party) (48), what is the total of all payments related to the structured settlement included in the total amounts of gross payments (46)? 77. What were the brokerage and other fees related to structured settlement? 78. (non-fla claims only:) Did the claimant s injuries overcome the tort threshold? 1 = Yes 2 = No 3 = FLA Claim 79. How was the tort threshold overcome? 1 = Death 2 = Permanent serious disfigurement 3 = Permanent serious impairment of an important physical function 4 = Permanent serious impairment of an important mental function 5 = Permanent serious impairment of an important psychological function 6 = Threshold not overcome 7 = Unknown 17 P age