State Farm Canada has filed a statement of claim seeking a total of $21 million in damages from several Ontario health service providers and individuals.
State Farm's statement of claim contains allegations not proven in court. It alleges that six health clinics and eight individuals were involved in a conspiracy to submit "false and fraudulent documentation" to State Farm related to accident benefits claims.
State Farm's statement of claim requests a declaration from the court that the insurer is no longer required to pay any future or outstanding bills to the defendants.
The companies listed in the statement of claim include a numbered company and Pacific Assessment Centre Inc., Fairview Assessment Centre Inc., MD Consult Inc., MD Assessment Consult Inc. and Traffic Law Advocate (E.E.) Professional Corporation.
Phone calls to the Pacific Assessment Centre and the law firm believed to be representing the defendants were not returned.
"Auto insurance fraud, specifically accident benefit fraud, continues to be a serious industry and consumer problem in Ontario," said John Bordignon, State Farm's media representative. "Clearly, insurance fraud is a criminal activity that affects everyone. This is not a victimless crime. It's a crime we all pay for.
"We have seen progress since the Ontario government's mandated auto insurance reforms were implemented in September 2010, and the provincial anti-fraud task force will shed more light on this issue and craft positive recommendations to combat it.
"State Farm is committed to working with our industry partners, regulators and the government to reduce the impact insurance fraud has on consumers."
Friday, November 18, 2011
Injured claimant's adaptive ability should be based on more than just an inability to return to work: Ontario arbitrator
An injured person's ability to adapt to stressful circumstances is broader than just whether or not a person can return to work, an Ontario arbitrator has found.
Adaptability is one of four factors used to determine whether a person's mental or psychological impairments due to an auto collision qualify as "catastrophic." A catastrophic injury designation in Ontario qualifies the claimant for substantially increased accident benefits.
In reaching her conclusion, Financial Services Commission of Ontario (FSCO) arbitrator Rosemary Muzzi found in favour of Intact Insurance Company, which submitted that claimant Carrie Leach had not sustained a catastrophic impairment.
Leach was injured in motor vehicle accident in 2003. Her assessors found she had a moderate impairment in three out of four categories of function used to determine a catastrophic impairment.
The four categories of function include an assessment of:
• activities of daily living,
• social functioning,
• concentration, persistence and pace and
• deterioration in work or work-like settings, or repeated failure to adapt to stressful circumstances (adaptation).
Leach's assessors said Leach showed a "marked" impairment in the adaptation area of function. This was based on Leach's inability to complete a work placement at a local school as a teaching assistant in a vocational hair styling course.
Leach's marked impairment in the adaptive category alone was enough to have her classified as catastrophically impaired, the assessors argued.
Intact argued a marked impairment must be present in more than just one of the four areas used to assess the effects of psychological impairment.
But Muzzi found Leach did not even have a marked impairment in the area of adaptation, saying consideration of a person's adaptive ability should go beyond an inability to return to work.
"Ms. Leach's assessment team focused on Ms. Leach's ability to tolerate work as demonstrated in her unsuccessful work placement at a local school as a teaching assistant in a vocational hair styling course," Muzzi wrote. "I considered her work placement experience from a broader perspective and also examined her ability to tolerate stress in her other life activities and found her to be reasonably capable and flexible and only moderately impaired in this regard."
Adaptability is one of four factors used to determine whether a person's mental or psychological impairments due to an auto collision qualify as "catastrophic." A catastrophic injury designation in Ontario qualifies the claimant for substantially increased accident benefits.
In reaching her conclusion, Financial Services Commission of Ontario (FSCO) arbitrator Rosemary Muzzi found in favour of Intact Insurance Company, which submitted that claimant Carrie Leach had not sustained a catastrophic impairment.
Leach was injured in motor vehicle accident in 2003. Her assessors found she had a moderate impairment in three out of four categories of function used to determine a catastrophic impairment.
The four categories of function include an assessment of:
• activities of daily living,
• social functioning,
• concentration, persistence and pace and
• deterioration in work or work-like settings, or repeated failure to adapt to stressful circumstances (adaptation).
Leach's assessors said Leach showed a "marked" impairment in the adaptation area of function. This was based on Leach's inability to complete a work placement at a local school as a teaching assistant in a vocational hair styling course.
Leach's marked impairment in the adaptive category alone was enough to have her classified as catastrophically impaired, the assessors argued.
Intact argued a marked impairment must be present in more than just one of the four areas used to assess the effects of psychological impairment.
But Muzzi found Leach did not even have a marked impairment in the area of adaptation, saying consideration of a person's adaptive ability should go beyond an inability to return to work.
"Ms. Leach's assessment team focused on Ms. Leach's ability to tolerate work as demonstrated in her unsuccessful work placement at a local school as a teaching assistant in a vocational hair styling course," Muzzi wrote. "I considered her work placement experience from a broader perspective and also examined her ability to tolerate stress in her other life activities and found her to be reasonably capable and flexible and only moderately impaired in this regard."
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