An amendment to Ontario's Insurance Act will essentially allow insurers to challenge claims suspected to be fraudulent by refusing to pay for treatment plans until the treatment providers produce reasonable information.
Ontario Regulation 194/11 takes effect on July 1, 2011. The regulation gives insurers the authority to request the following information from treatment providers, who will have 10 business days to produce it after receiving the request:
• the originals of any treatment confirmation form, treatment and assessment plan, assessment of attendant care needs and other documents giving rise to the claim for payment;
• a statutory declaration as to the circumstances that give rise to the invoice, including particulars of the goods and services provided; and
• the name and full address of the provider, and of every provider that provided any of the goods or services referred to in the invoice.
Should a provider fail to comply, the amount payable by an insurer under an invoice is not overdue and no interest accrues on it, the regulation continues.
And finally, under the regulation, an insured is unable to commence a mediation proceeding if any of the following circumstances exist:
• the insured has not notified the insurer of the circumstances giving rise to a claim for a benefit or has not submitted an application for a benefit within the times prescribed;
• the insurer has provided the claimant with notice that it requires an examination under section 44, but the insured has not complied; and
• the issue in dispute relates to the insurer's denial of liability to pay an amount under an invoice on the grounds that the insurer requested information from a provider under subsection 46.2(1), and 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.
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