What FSRA’s telling healthcare providers to do if auto insurers deny certain claims

Ontario’s P&C insurance regulator is reminding carriers of their duty to cover necessary medical and rehabilitation expenses for auto accident insureds — and that includes their health service providers’ (HSPs) travel time expenses. 

A recent FSRA review of Health Claims for Auto Insurance (HCAI) data confirms insurers nationwide have been denying larger numbers of travel time expenses. The regulator did not provide specific figures.  

FSRA says it conducted the review after receiving several inquiries from HSPs about increasing denials of provider travel time expense claims. 

“This raises concerns with FSRA, which is why we will continue to monitor this situation, such as through the [HCAI] system,” the regulator tells Canadian Underwriter in a statement. 

“FSRA will thoroughly review each complaint raised by consumers or industry professionals regarding systemic or blanket denials to determine if insurers are meeting their legal obligations.” 

Travel time is a listed expense: FSRA 

Insurers’ statutory obligations to pay for reasonable and necessary medical and rehabilitation expenses are outlined in sections 15 and 16 of the Statutory Accident Benefits Schedule (SABS). This could include provider travel time expenses if it’s previously agreed upon, says FSRA. 

An insured would generally be expected to visit an HSPs place of business for their medical or rehabilitation services. 

But HSPs are able to fill out an OCF-18 (Treatment and Assessment Plan) and obtain an insurer’s prior agreement to pay for the provider’s travel time to render services at an insured’s home, school, workplace or community setting, for example. 

In those cases, the SABS requires insurers to agree to and pay for the HSP’s travel time, according to what is deemed “reasonable and necessary,” according to the circumstance. 

“It’s essential that insurers comply with their legal obligations,” the regulator says, adding “denials alone are not evidence of regulatory non-compliance.” 

The regulator is encouraging any HSPs who believe an insurer has contravened the Insurance Act to file a complaint with FSRA. 

A disagreement between an insured person and an insurer over whether any provider travel proposed in an OCF-18 is “reasonable and necessary” would be managed through the dispute resolution process. HSPs who feel their travel time expenses were unfairly denied are encouraged to speak with their insurer or bring the dispute to the Licensing Appeals Tribunal.