IBC lauds Ontario’s new anti-fraud regs

Regulation 194/11 strengthens the insurer's right to access medical invoices claimed by insured clients.

Insurance Bureau of Canada (IBC) is praising Ontario for enacting new regulations to cut down on insurance fraud. The new Regulation 194/11 strengthens the insurers right to access medical invoices claimed by insured clients.

“We are pleased that our industry will have additional resources with which to combat fraudulent activity which affects the insurance industry, and most importantly, the consumers we serve,” said Ralph Palumbo, vice-president IBC, Ontario. “We commend the work of FSCO in this regard, and, of course, the government for taking this timely and appropriate action.”

IBC hailed recently fraud laid charges, against the director of a Toronto area medical rehabilitation clinic, as evidence that the Financial Services Commission of Ontario (FSCO) is cracking down on insurance fraud.

Under the regulation, an insurer may request any information from healthcare providers that would assist it in determining its liability for payment. This gives the insurer the right to copy “any treatment confirmation form, treatment and assessment plan, assessment of attendant care needs and other documents giving rise to the claim for payment.”

Insurers may also request a statutory declaration explaining the circumstances that led to a service invoice being issued, including a list of all goods and services provided.

A service provider who issues an invoice may also be required to provide proof of their identity as well as their business address.

These providers must submit all requested information to the insurer within 10 business days of receiving the request. If there is any delay in delivery, the insurer is not liable for any interest that accrues on the original invoice.

Section 55 of the regulation, regarding mediation proceedings, has been rewritten. Under the new regulation, mediation may not commence if:

  1. The insured person has not notified the insurer of the circumstances giving rise to a claim for a benefit or has not submitted an application for the benefit within the times prescribed by this Regulation.
  2. The insurer has provided the insured person with notice in accordance with this Regulation that it requires an examination under section 44, but the insured person has not complied with that section.
  3. The issue in dispute relates to the insurer’s denial of liability to pay an amount under an invoice on the grounds that,
    1. the insurer requested information from a provider under subsection 46.2 (1), and
    2. the insurer is unable, acting reasonably, to determine its liability for the amount payable under the invoice because the provider has not complied with the request in whole or in part.

The new regulation comes into effect July 1, 2011.

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