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Tag Archive for: Auto Insurance


Increasing Form 1 Rates Equals LESS CARE for Injured People in Ontario

Julie Entwistle, MBA, BHSc (OT), BSc (Health / Gerontology)

I can only imagine that the general public is getting overwhelmed and confused by all the recent media, hype and dialogue over the current state of car insurance in Ontario.  The sad reality is that until you need your car insurance because you have been injured, you are likely not going to understand it.

But for those of us that work in this sector, understanding, fighting and trying to bring clarity to the challenging opinions of government, third-party consultants and insurers is a daunting task.

My only ask is why can’t the insurance sector be ruled by logic? 

Here is my latest example:

If you are injured in a car accident you may need care.  This is time other people will spend helping you manage the most basic activities – getting dressed, showering, taking medication, being safe in your home, etc.  The monies you have available for this care is calculated through a document completed by an Occupational Therapist (or a nurse).  It is actually pretty simple – an occupational therapist does an assessment, calculates the amount of care, and that is the care that can be provided.  But here is the lack of logic in how insurer’s and the industry seem to be interpreting this form to the disadvantage of the consumer:

1.      There is a cap to the maximum amount you will get anyway.  So, if you need $8000 in care per month, you will only get $3000 or $6000 depending on if you have a catastrophic injury or not.

2.      If your family wants to provide some care, they can’t get paid any of this money unless they are off work or incur an “economic loss” to provide the care.

3.      If your family is suffering an “economic loss” providing the care, they will only be paid the amount per hour of the form, not their actual loss, and the monthly maximum applies.

4.      As per a recent “raise” for care providers, the amount that is paid per hour for the services ranges from $14.00 to $21.11 per hour.  If your family member was making more than this per hour, it would cause hardship for your family if they decided to provide your care for a lesser rate of pay.  So, your option would be to hire help.

5.      PSW’s can provide this care, but they are typically $25-$30 / hour.  So, the services you need you cannot get because they charge more than the form allows.  The result is you get less help than you need because the time runs out faster when you are paying more.

6.      If your accident happened before January 1, 2018 then you actually don’t even get today’s minimum wage for your care.  You get the minimum wage (or less) for the time that your accident happened.  So, if your accident was before October 1, 2003 you are required to find or hire care for $7.00 per hour (see the below rate chart).

7.      There are two amounts in the document.  The “total” of all the time added up, and the “minute” time calculated for each section.  Some (many) insurers are now taking the position that they will pay for the “minute” time, not the “entire time”.  So, if I assess you to need 30 minutes per day of care that comes to $210 per month, the insurer will only pay for 30 minutes per day.  But PSW companies have minimums so they won’t come to your house for 30 minutes per day – they want 2 hours at the least.  But the insurer won’t pay them for 2 hours up to $210, they will only pay for $7.00 per day.

8.      Even if you can get your care at the amounts allowed, this will still come from your total claim budget that is also used for rehabilitation.  The choice becomes – get care or get better?

All of this to say that the system is not easy to navigate and getting the care you need will prove difficult.

So, what are the options?

Well, if minimum wage is going to continue to increase then it would only seem appropriate that ALL people with an OPEN CLAIM get TODAY’s rates for care – after all, it is today that they need the services – not in the era of their date of loss. 

It would also seem appropriate that the maximums for care coverage INCREASE proportionately to the raise in care pricing.   So, if $3000 a month was an appropriate maximum in 2003 when the care was at its lowest ($7.00 / hour), then why do we have the same maximum when the care costs have doubled?

Trying some simple math…

If I was eligible for 24-hour care in 2003 at a maximum of $3000, under the Level 2 rate then (see chart) of $7.00 / hour, I could get 14 hours of care (if family was willing to work for that).

If I am eligible for 24-hour care today at a maximum of $3000, under the new Level 2 rates of $14.00 / hour, I get 7 hours of care (if family was willing to work for that).

So, increasing the minimum wage for care providers only makes people get to the maximum more quickly, providing them access to LESS CARE. Thus, in the absence of an increase in the maximum’s allowed, these higher care costs are reducing people’s ability to get the total care they need.

My suggestion is that if the industry could be ruled by logic, then the maximums would increase with the care cost changes.  Using an average of care costs, here is where I think the maximums should be:

2003 average ((9+7+15)/3) = $10.33 per hour

2018 average (($14.90+14+$21.11)/3) = $16.67 per hour

% change between 2003 to 2018 = $16.67-$10.33 / $10.33 X 100 = 61%

So, if the hourly rate has increased 61% in 15 years, then wouldn’t logic tell us that the maximums for care should also increase by that same percentage:

$3000 (maximum in 2003) becomes $4830

$6000 (maximum in 2003) becomes $9660

Auto insurers have eroded so much from the customers of Ontario over the last 8 years and while this subtle increase in care costs seem to be provided in “good faith” to align with minimum wage increases, they actually cause people to get less care as they just reach the maximums more quickly.  Then, they create significant payment issues when they nickel and dime the form and pay by the minute.  Rock meet hard place.

However, I realize fully that even if insurers decided to proportionally increase care maximums as I have suggested, I know this care now comes out of a bigger budget that includes rehabilitation (when before care had its own budget).  These budgets are currently $65,000 (was $172,000) and $1,000,000 (was $2,000,000).  But the system is currently set-up for people to have “choice” between care and rehabilitation, so I still think the choice should be fair in that at care prices today, the maximums need to be increased.

If insurers really cared about people getting the personal support they need post-accident, they would:

1.      Pay today’s rates for everyone with an open claim.

2.      Increase the maximums proportionally to the increase in hourly pay.

3.      Make it easy for people to get the care – pay to the amount of the form so people can choose to pay a bit more for private services if that is what they need – it all comes out of the same budget anyway, so I am not sure why payment needs to be made difficult too.

The choice is ultimately care or rehabilitation…too bad when our premiums remain high and the outcomes of these losses can be devastating. 

For those working in the sector, here is the chart of rates spanning the last 15 years.


A MUST READ New Guideline for Insurance OTs in Ontario

Julie Entwistle, MBA, BHSc (OT), BSc (Health / Gerontology)

With all the legislative changes in the very contentious auto insurance industry, it can be hard to stay current.  Case law, reports, position papers, and of course the high-profile circulations of the Toronto Star.  But sometimes what goes unnoticed is the work of the Colleges or Professional Associations that spend time and resources trying to provide guidance and support to those of us working in this everchanging area of practice.

In the world of Occupational Therapy, one recent document has been posted by the College of Occupational Therapists of Ontario that thoroughly speaks to the challenges, college expectations and tug-of-war that OT’s experience in this difficult sector.  This circulation, entitled “Guideline for Working with Third Party Payers” is a must-read for OT’s in the insurance industry, and serves as a useful tool for anyone (clients, lawyers, insurers, other professionals) who retain, work with, or otherwise engage with an OT for assessment or treatment services.  The guideline ( covers all important aspects of practice in the world of third party work, and includes the following summarized sections:

Providing Ethical and Competent Client Care reviews the Ethical responsibilities of the OT to be transparent, fair and impartial.

Defining Your Role and Setting Expectations with Stakeholders addresses how important it is for OT’s to follow the Standards for OT Assessment and to understand the limits to their own competencies when accepting referrals.

Consent and Personal Health Information discusses how to manage difficult consent situations, for example if another person indicates they got “consent” for the OT, or if a client later withdraws consent during an assessment or treatment. Importantly, it also talks to an OT’s requirement to get new consent when presented with a request to review or comment on new information that was not received when initial consent was obtained.  The submission of reports in draft form to third parties is also covered.

Managing Records and Reports reminds OT’s of their responsibility with record keeping, privacy legislation, and of course the client’s right to access their records.

Managing Conflicts of Interest considers the challenges in this high-stakes industry that is fraught with important funding decisions, conflicting agendas, and relationships that can be formed with clients, insurers, lawyers and the like.  This section deals with these competing interests, conflicting standards and opinions, personal conflicts between oneself and third parties, companies or even other professionals.  Also covered in this section is referrals received from friends or family members, being requested to observe an independent medical exam, and treating clients that are related.  OT’s are reminded that practicing within a conflict of interest (perceived, real or implied) is considered professional misconduct.

Managing Professional Boundaries are addressed and this section highlights different types of potential boundary crossings with clients and referral sources / payers.  It speaks to monetary relationships and financial / gift incentives as a boundary crossing and one that can jeopardize client outcomes and breach professional boundaries.

Use of Title is discussed as a reminder to the different titles an OT may have in providing service, and how to be clear about their role at all times.

Independent Practice reviews the nature of being an “independent contractor or provider” and the resources available to set up, and run, an independent operation.

Lastly, the guideline covers the expectations for providing services to clients who Live Outside of Ontario and reminds OT’s that the client’s location, not theirs, is the jurisdictional boundary and practicing outside of Ontario is not permitted unless the OT has a license in that location as well.

Overall, this document is a useful tool and hard reminder to OT’s of their obligations and expectations as licensed professionals in Ontario.  It may also prove helpful for other stakeholders to review, such that they too understand the rules and boundaries on OT’s so that they can be mindful of these in their working relationships with us.


The GOS-E and Catastrophic Determination – Gathering EVIDENCE of Pre-Accident Function

Julie Entwistle, MBA, BHSc (OT), BSc (Health / Gerontology)

Over the last few months we have had the privilege of presenting to a multitude of Personal Injury Lawyers on the June 1, 2016 changes to catastrophic determination, most specifically on the Glascow Outcome Scale Extended (GOS-E).  If you are working in motor vehicle accident (MVA) rehabilitation or personal injury law, this scale is one you need to be familiar with.

To qualify for catastrophic under the GOS-E, it speaks openly about changes to QUALITY and FREQUENCY of participation in pre-accident tasks under the facets of independence in and outside the home, travelling locally and abroad, productivity, social / leisure participation and relationships.  Within this, it considers HOW OFTEN someone did something, but even bigger than that is FOR HOW LONG and at WHAT INTENSITY.

As OT’s working in this sector, it is important that we gather this information in great detail during our initial assessment to not only get a better picture of pre-accident lifestyle and function, but to create early records that could relate to catastrophic determination at 6 months, 1 or 2 years’ post-accident.

During a presentation, one lawyer questioned the “qualitative way” by which pre-accident information is usually gathered (by asking family or through client self-report).  He asked if there was better evidence, “proof” if you will, that could speak objectively to “pre-accident function”.  This was a great question because right now the only pre-accident “evidence” the industry tends to gather are medical records and these speak to health, not function (and the two can be very different).  Function is best outlined by finding out how people spent their time – something that one would think would be difficult to objectively measure for the purpose of “evidence”, but let’s think again.

The evidence of how people spend their time is actually everywhere.  My morning dog walk and sleep habits are tracked on my fit bit and transferred to my computer and phone.  My car logs the kilometers I drive, and the repair shop inputs these with every oil change.  The gym tracks my attendance.  My phone apparently stalks me by recording everywhere I take it, the websites I visit, the apps I use and the people I speak to, text and email.  The photos in my phone also tell the story of my life and where my time is spent.  My computer records the number of emails I send and receive and the places I visit online.   My emails are sorted and can detail the time I spend organizing and taking trips (local and abroad), socializing, and even my relationship communication habits.  If I had a personal Facebook account this would detail for you the people I chat with, how often, and the places I visit, take photos and upload.  Twitter, Instagram and Snapchat would do the same.  But honestly most of the information about my time spent would be easily revealed through my financial records.  Most of the things I do cost money.  My credit card and bank statements will show you the frequency by which I get a latte, the costs for my gym program, the amount of shopping I do, the people I pay to help manage aspects of my house, the places I eat or indulge, the number of times I visit the movies or do something fun, the things I enroll my children in, etc.  These will even tell you the therapies or treatments I might get privately that my doctor doesn’t even know about.

We know that being involved in the insurance system exposes aspects of people’s lives that they may not want to share.  All privacy is forgone when you want and need help from an insurer, or when you want and need to sue someone who was at-fault for causing you injury and harm.  Unfortunately, with the changes to Catastrophic Determination, the gap just widened in terms of the information that needs to be gathered and the “proof” that needs to be provided to access the benefits an injured person may need.  However, the information is out there – little is sacred or private anymore. 

If this is helpful, here is a list of information that could be gathered to support changes to FREQUENCY and QUALITY of participation in most activities before and after an accident.   Getting someone’s personal records for the year prior to an accident, and then for the first-year post, will be highly informative, helpful and revealing…if they are agreeable to share:

Bank Statements / Financial Records will show MOST purchases related to social / leisure activities:

Memberships / clubs / subscriptions
Dinners / coffees / movies
Shopping habits
Sports / fitness
Gas / driving / parking habits

Other places will also have records:

Gym / rec center attendance
Schools / school records
Employment records
Evidence of trips / vacations / social events on SM – FB, Twitter etc (before the accident)
Car / vehicle records – how often the car was driven based on KM’s
Points cards for anything like movies, Starbucks, Airlines, etc
Call / cell records and communication habits
Medical records

I hope this helps the lawyers and injured people of the insurance system to find the “evidence” they might need to really demonstrate to an insurer how their life has been impacted following an accident.  And for the OT’s gathering similar data subjectively, be specific and thorough in your questioning under the GOS-E spheres.  Your reports are highly important and may become the difference between someone being deemed catastrophic or not.


Is the Sky Falling? Auto Insurance Changes June 2016

Julie Entwistle, MBA, BHSc (OT), BSc (Health / Gerontology)

In June 2016 the Statutory Accident Benefits Schedule will change again.  I say “again” because in my relatively short sixteen year lifespan working in auto, the industry has gone through some major plastic surgery.  It is becoming less and less recognizable as it is nipped and tucked once more, becoming almost unrecognizable as the mandatory product we all purchase to be covered in the event of an accident.

Since the announcement of the upcoming changes, the common reaction is comparable to the story of Henny-Penny and Chicken-Little who create hysteria after an acorn falls on Chicken-Little’s head.  In earlier versions of the Chicken-Little story all the paranoid animals get lured and eaten by the fox.  Later versions of course have the animals living happily ever after, or finally understanding Newton’s law.

So, is the sky falling in Ontario’s auto insurance?  Well, I won’t say things are all unicorns and rainbows.  As of June 2016 all Ontario drivers will be paying relatively the same dollars for 50-98% of the coverage.  Attendant care and medical rehabilitation monies are being combined, resulting in reductions in coverage totalling $21K for seriously injured people and $1M for those that are deemed catastrophic.  On top of that, the industry will revise the criteria for catastrophic status so less people will qualify in the first place.  As a consumer, it is infuriating that my premiums are not changing to the $50 / year that this new coverage is worth.  As an OT that has clients running out of monies now, this does seem like the sky is falling.  Take for example my 16 year old client with C5 tetraplegia.  One million dollars in combined coverage will not last long for someone that is young, has a permanent impairment, who requires 24 hour care (and sometimes the care of two people simultaneously), and who will require a fully accessible home and vehicle so that his basic needs can be met.  And that does not even speak to the costs for the many therapies, wheelchairs, lifts and other treatments needed, nor the costs to get him education support and engaging in activities that he will find both meaningful and productive.

From a consumer and client perspective I am concerned.  While there is an option to “buy up” for decent coverage, most people don’t exercise this under the “it won’t happen to me” facade.  However, as a wanna-be optimist, from a professional and business perspective I can still help a lot of people with $65K or $1M in coverage.  That is a lot more money available than the $0 my clients with ALS, MS, stroke, or cancer ever receive.

So, Chicken-Little, Henny-Penny and friends overreacted.  They panicked.  They caused chaos.  I, on the other-hand, am choosing to take the adaptive approach.  Where are the opportunities?  What is still good about the coverage that remains?  Where can I still add value and help people?  How can I be proactive instead of reactive?  What initiatives can I support that are advocating for client and consumer protection?  What can I do in my practice to make $65K and $1M last as long as possible?  Call me Julie-Fooley, and perhaps I will be eaten by Fox-FSCO, but I still want to believe in happy endings.


Auto Insurance: How Much Have you Overpaid?

A recent study conducted by the Ontario Trial Lawyers Association shows that between 2001 and 2013 Ontarians have overpaid an estimated $3 to $4 billion in auto insurance premiums.  The recent Ontario budget calls for a reduction to these premiums, but at a huge cost in accident benefits.  Find out more about the study and help by signing the petition to stop the reduction to benefits for accident victims.

CBC:  Ontario drivers overpaid $840M for auto insurance a year, study says

Petition:  Stop Reducing Ontario Accident Benefits