Automobile Insurance Third Party Liability Bodily Injury Closed Claim Study in Ontario

August 13, 2014

Contents

Introduction

Reliances and Limitations

Selected Observations

Data

Claim Survey Development

Claim Sample Numbers

Data Collection Process

Data Validation

Auto Ontario Incurred Loss Development Report

Gross Weekly Wage Comparison

Age Distribution

Overall Data Summaries

Appendices

 


 

Introduction


Pinnacle Actuarial Resources, Inc. (Pinnacle) was engaged by the Financial Services Commission of Ontario (FSCO) to conduct a study of automobile insurance third party liability bodily injury (BI) claims in Ontario. The purpose of the study is to provide a detailed analysis of costs and other factors relating to claims that have been filed, processed and closed by insurance companies in Ontario. Pinnacle was responsible for designing the study, conducting the data collection, and developing a report based on the study results.

The closed claim study was to provide necessary data not available from other sources to better enable FSCO to understand the factors contributing to cost changes and to use as a framework for analyzing tort settlement costs and other factors that could have an impact on the Ontario automobile insurance system. The study is important to the government as it will also assist in evaluating the factors affecting the costs of future product changes pertaining to BI claims. In addition, the closed claim study will supplement data collected by statistical plans.

The data that was analyzed in this study was collected from auto insurers in conjunction with FSCO and Insurance Bureau of Canada (IBC). IBC is the national association representing Canada's private home, car and business insurance companies.

The last closed claim study conducted in Ontario was in 1987, with the results published in the Report of Inquiry into Motor Vehicle Accident Compensation in Ontario (Osborne report) by the Honourable Mr. Justice Coulter A. Osborne in 1988. The study covered Ontario automobile BI claims closed during 1986 and accident benefit claims for accidents that occurred in 1985.

In order to account for the time it took stakeholders to become familiar with the 2003 reforms in the Ontario auto insurance system under Bill 198, this study surveyed private passenger automobile BI claims for accidents that occurred in calendar year 2005.

Reliances and Limitations


In developing this report, Pinnacle has relied upon data and information supplied by the claim representatives of the automobile insurance companies that participated in the study. Pinnacle relied upon the general accuracy of this data and information without independent verification.  However, Pinnacle did review certain elements of this data and information for reasonableness and consistency with our knowledge of the insurance industry and the claims process. Pinnacle also validated that data provided was internally consistent. Any errors or omissions in the data provided could have a material effect on our analysis of the drivers of loss costs.

The analysis of the loss experience was for claims that occurred in 2005. As such, any projection of the results of this data into the current claims environment involves estimates of the impact of differences in the legal environment now as opposed to 2005. Therefore, any such projections are subject to economic and statistical variation.  No assurances can be offered that the results of this claim study will be representative of today’s conditions.

We have assumed that no significant differences in claims management or philosophy exist between the individual companies that participated in the survey.

Other reliances and limitations and specific assumptions and data adjustments are cited in this report and in the attached exhibits that are an integral part of this report.

Selected Observations


Selected observations from the study are listed below.

1.      The average gross payment to claimant was just under $120,000, while the median payment was $56,500.

2.      Special damages account for 12% of the total gross payments (comprised of general damages, special damages, party and party costs, disbursements and prejudgment interest) to the claimants. The largest category of special damages payments is for loss of income, which includes lost wages (34%) and other income loss (18%). Housekeeping services are the second largest category of special damages at 31%.

3.      General damages account for 64% of the total gross payments to the claimant.  Non-pecuniary damages (pain and suffering) represent the largest portion of the general damages, accounting for 53% of the total general damages payments. As a percentage of the total gross payments to the claimant, non-pecuniary damages account for 35% of the total gross payments to the claimant.

4.      Total insurer reported external counsel costs were about 9.2% of the total gross payments. Overall, total insurer reported costs were 14.3% of total gross payments.

5.      Overall, there was an average of 1.11 claimants per claim occurrence.

6.      Over 43% of the claims surveyed occurred in GISA Statistical Territory (Territory) 717 that includes Toronto, Markham, Richmond Hill, Vaughan, Brampton and Mississauga. For gross payment severity, the largest severities occurred in Territory 722, which is Northwestern Ontario. The average severity in this Territory is almost twice the overall average.

7.      The highest average gross payment severities by claimant role are for motorcycle drivers and motorcycle passengers. The total gross payment average severity for motorcycle drivers is 2.7 times the overall average and the average severity for motorcycle passengers is 1.6 times the overall average gross payment severity. Passengers in the named insured vehicle are the next highest, with a severity of 1.5 times the average, followed by pedestrians, with a severity of 8% higher than average. The severities for named insureds in the insured vehicle are about 7% higher than average.

8.      The highest average gross payment severity by GISA Type of Use Code was for code 09, married males under the age of 25. The second and third highest severities were for unmarried males under age 20 and occasional females under age 25.

9.      Gross payment severity by claimant age increases through age 20, and then decreases as the age of the claimant increases beyond 20.

10.  For accidents that occur between 12:00 a.m. and 3:00 a.m., the average gross payment severity is 25% to 46% higher than average.

11.  Soft tissue injuries (neck and back sprains) were associated with claimants who accounted for 67% of the total claim payments in the survey. Similarly, roughly 70% of the claimants in the survey were classified as having no injuries or having minimal or minor injuries in the police report.

12.  The severity for mild neck strains was about 50% of the overall average gross payment severity, the severity for moderate neck strains was roughly equal to the average gross payment severity, and the severity for severe neck strains was almost 2.5 times the overall average gross payment severity.

13.  The claimant count shows that 91% of the claimants had some type of legal representation.  In the Osborne report, 54% of claimants had legal representation.

14.  The majority of claimants ultimately commenced legal action against the insurer (83%). This is an increase of 60% since the Osborne report. The ultimate severity for claims in which legal action commenced was 14% higher than average.

15.  The percentage of claimants with psychological trauma increased from 1.1% in the Osborne report to 36.2% in the current study. The percentage of claimants with mild neck injuries and mild back injuries increased as well, going from 3.4% to 27.2% and 1.5% to 25.3%, respectively. The percentage of claimants with shoulder soft tissue injuries also increased by 15.3%, going from 14.9% to 30.2%.

16.  The percentage of claimants with soft tissue neck injuries decreased from the Osborne report to the current study, going from 58.7% to 36.1%.

17.  The actual time lost from work increased from the Osborne report to the current claim study. In the Osborne report, the median time lost from work was two months. In the current claim study, the median time lost is seven months.

18.  In the Osborne report, 77% of the claims were settled before an action commenced. In the current claim study, 16% of the claims were settled before an action commenced.

Data

 

Claim Survey Development

To complete this analysis, Pinnacle worked with FSCO and IBC, as the trade association, to develop a survey questionnaire that company representatives would need to complete for each selected claim. A draft of the questions was developed by Pinnacle, using as input our experience as well as elements from the following previously completed studies:

·         Report of Inquiry into Motor Vehicle Accident Compensation in Ontario, 1988

·         New Brunswick Closed Claim Study, 2011

·         Private Passenger Automobile Closed Claim Study – 2004: Newfoundland and Labrador

·         Alberta Closed Claim Study, 2006

·         No-Fault Auto Injury Claims in Michigan: A Study of Closed Claims and Open Catastrophic Claims, 2012

Once the draft questions were developed, the draft was provided to FSCO and IBC, who provided additional questions and input on the draft questions. The questions were also designed to ensure that the current survey questions would allow the results of this study to be compared with the results of the Osborne report to the extent possible. Also, in an effort to reduce the time and effort required to complete a survey for each claim, questions which were deemed insignificant were removed from the questionnaire. Once the input from FSCO and IBC was incorporated, the survey was provided to the participating insurance companies for their feedback.  Insurer feedback was evaluated and incorporated into the survey questionnaire.

In addition to the questionnaire, Pinnacle also developed an Excel form to facilitate the data input by companies and to increase the consistency of the information submitted.

The final claim survey questionnaire and survey completion instructions are included as Appendix 1.

Claim Sample Numbers

Companies were identified for participation in the study based on their market share in 2005. Data submitted by insurers to the Automobile Statistical Plan was used. The goal for the study was to obtain a representative sample of 3,500 – 4,500 claims files from 10 to 13 Ontario auto insurers representing 70 – 80% of the market share in 2005. A table of insurers chosen to participate in the survey are shown below.


 

Table 1: Participating Ontario Auto Insurance Companies

Group/Co.

Aviva Group

Intact Group

State Farm Group

TD Insurance Group

Economical Group

Cooperators Group

Dominion of Canada

Northbridge Group

RSA Group

Desjardins Group

Allstate Group

Wawanesa Mutual Insurance

 

The total number of claims to be sampled was selected to be consistent with the overall distribution of claims by company and Territory.

Data Collection Process

There were a number of steps taken during the data collection process to ensure accuracy and consistency of the data collected.

Once the survey and number of claims for each company were finalized, Pinnacle held a training session for company claim representatives. During this training, Pinnacle reviewed the claim survey questions to clarify the data that was being requested, the Excel form to be used for the data collection, and the data collection process. Pinnacle also answered any questions that the companies had.

Once the training was complete, each company completed 20 claim surveys and submitted the results electronically to Pinnacle to review. Pinnacle reviewed these initial 20 responses and provided feedback to each company on the surveys to ensure the questions were being answered correctly and consistently.

After the initial survey responses were completed, companies then submitted the completed surveys to Pinnacle weekly for review. Pinnacle reviewed the weekly submissions, checking for errors and inconsistencies in the answers, and provided reports back to companies based on our review. Companies then reviewed the responses, and if necessary, corrected the submissions and resubmitted the responses to Pinnacle.

Pinnacle also held bi-weekly conference calls with the insurance companies. The purpose of these calls was to answer any questions that the insurance companies had, to discuss any general observations or clarifications based on our review of the survey responses, and to discuss the companies’ progress in completing the survey questions.

For each company submission, Pinnacle conducted error checks on the data to ensure that the data was correct and reported consistently between companies. The types of checks that were conducted included:

·         Duplicate entries

·         Missing key data fields

·         Inconsistent entries (e.g., indicated no injury occurred but also checked another entry type)

·         Ensuring that total claim amounts equal the sum of the underlying claim amount entries

Data Validation

To validate that the responses to the claim surveys were consistent with external information, we compared the responses to the survey questions with several external data sources.

Auto Ontario Incurred Loss Development Report

Pinnacle was provided with the General Insurance Statistical Agency (GISA) 2012-1 Incurred Loss Development Report for Private Passenger Auto. As part of this report, incurred to date and projected Bodily Injury total losses and claim counts are included for the industry for Ontario. For 2005, the average bodily injury severity including loss and allocated loss adjustment expense (ALAE) was approximately $145,000. As will be seen later in this report, the average gross payments from the claim survey were $119,816 without ALAE. When adding a conservative estimate for ALAE developed from the claim survey, the average severity for the claim survey was $137,000. This also excludes the incurred amounts from open claims, which would increase this average as well. Therefore the average amounts from the survey track well with the average projected amount from the industry report.

Gross Weekly Wage Comparison

The gross weekly wage was reported for just over 2,500 of the claimants in the claim survey. The average reported weekly wage for those claimants where the weekly wage was reported was $887. Based on the Human Resources and Skills Development Canada office, the average weekly wage for Ontario in 2005 was $846. Therefore, the weekly wage numbers are consistent with external reports.

Age Distribution

We also looked at the distribution of ages in the claim survey data and compared this with the distribution of drivers and passengers injured in collisions in 2005 as reported by the Ontario Ministry of Transportation [1]. The distribution from the survey compared to the Ministry of Transportation data is shown below.

Table 2: Age Distribution

 

Age Category

Ministry of Transportation - Drivers and Passengers Injured in Collisions

 

Claim Survey Injured Claimants

Under 16

7.5%

3.2%

16 – 20

12.4%

5.6%

21-24

9.5%

5.3%

25-34

18.6%

17.6%

35-44

18.5%

23.3%

45-54

15.1%

22.2%

55-64

9.6%

13.4%

65 & Over

8.9%

9.3%

 

While the distribution is not identical, the distribution between the two sources is reasonably consistent, and therefore we are comfortable that the age data we received as part of the survey is reasonable.

Overall Data Summaries

In total, surveys were completed for 3,414 claim occurrences. For these claim occurrences, there were 3,804 claimants.  As a result of the data reviews and corrections, this final closed claim report is based on 3,049 claim occurrences. For these claim occurrences, there were 3,364 claimants.

 


 

Appendices

1.      Claim Survey Questions

2.      Injury Descriptions

3.      Error Checks Conducted

4.      Claim Survey Data Summaries

5.      GISA Type of Use Codes

6.      GISA Statistical Territory Codes

7.      Severity by Injury Type

8.      Comparison to Osborne Report


 

Appendix 1

Closed Automobile Insurance Third Party Liability Bodily Injury Claim Study in Ontario

 

Closed Automobile Insurance Third Party Liability Claim Study in Ontario

Survey Completion Instructions

 

1.      Please complete one record for each injured claimant resulting from the same accident. For example, if an accident gives rise to three injured claimants, three separate forms have to be completed.

a.      Regarding Family Law Act Claims, in the event of one injured claimant and multiple resulting FLA claims, fill out one form only. 

2.      Survey should be completed only for claims with indemnity payments (payments to claimants).

3.      Each company will be given a target number of claims and a list of claim numbers to be included in the sample. Companies will be provided with approximately 50% more claim numbers than the target number of claims.

4.      If the claim for a given ID cannot be found  due to wrong ID, claim files missing, claims closed without payment, etc. this ID should be skipped.

5.      If more than one relevant coverage (i.e. Bodily Injury, OPCF 44R) is involved in the claim occurrence, complete one survey response for each Bodily Injury claimant for each such coverage involved in each claim occurrence.

6.      Records can be completed either directly in the table or by using the form in the provided Excel file.

a.      If inputting or copying data into the ClaimsData sheet in Excel, the paste value approach should be used to preserve formatting used for data validation. 

7.      All fields must be completed. Using the form will result in needing to fill in fewer actual answers given that some answers will be determined based on answers to other questions. If answers are entered directly into the Excel spreadsheet table, each cell will need to be filled in.

8.      Please include requested amounts rounded to the nearest dollar.

9.      Please ensure that amounts that should balance to the answers of other questions do balance.

10.  All settlement amounts are to be shown gross of reinsurance recoveries, if any.  Where breakdowns of settlement amounts by heads of damage are required, these should be obtained from the award in the judgment in the case, after reduction for contributory negligence, if any.  If no such award exists (i.e. pre-trial settlement), then these breakdowns should be estimated in a reasonable fashion by a claims expert.  One way to do this might be to take the latest settlement offer produced by the claimant's legal counsel (when relevant), drop any heads of damage which the insurer thinks to be unreasonable, and prorate the actual settlement amount in proportion to the remaining heads of damage in the offer.

11.  All claimant demographic information should be provided as of the date of the accident.

12.  Each claimant should be interpreted as each injured person, regardless of who is actually claiming damages (e.g. Family Law Act Claims).

13.  For each injury category, check the boxes for all applicable injuries. For neck and back injuries, select the category (minor, moderate, or severe) related to the most serious medical injury in that category based on your professional judgment.

14.   All dates should be completed in “YYYYMMDD” format.

15.  All percentages should be entered as a whole number.

16.  20 sample claims should be completed and returned within two weeks of receiving this package.

a.      The sample responses will be reviewed and the results of this review will be communicated to each company.

b.      If, as a result of the training or the sample, clarifications to the instructions need to be made, this will be completed within one week of receiving the sample claim survey responses.

17.  Completed surveys as of the end of each week should be forwarded to Pinnacle for review.

18.  Company should continue the report until the target number of claims is reached.

If you have any questions as you are completing the survey, please contact Roosevelt Mosley or Nick Kucera.

Roosevelt Mosley
(309) 807-2330
rmosley@pinnacleactuaries.com

Nick Kucera
(630) 457-1293
nkucera@pinnacleactuaries.com

 


 

Survey Questions

Claim Information

1.      Company Number
_________________

2.      Initials of Person Completing the Form
_________________

3.      Claim Number
_________________

4.      Claimant Number
_________________

5.      Policy Number
_________________

6.      Claim Type

   1 = Bodily Injury (Includes uninsured motorist and unidentified motorist)

   2 = OPCF 44R

7.      What was the actual policy limit of the applicable coverage?
___________________

8.      What was the GISA Statistical Territory Code of your insured vehicle?
___________________

9.      What was the GISA Type of Use Code of your insured vehicle?
___________________

 

Accident Information

10.  What was the claimant’s role in the accident?

   1 = Driver of other than your insured’s vehicle

   2 = Passenger in other than your insured’s vehicle

   3 = Named insured driver

   4 = Named insured passenger in insured's vehicle

   5 = Passenger (not named insured) in insured's vehicle

   6 = Pedestrian

   7 = Motorcycle driver

   8 = Motorcycle passenger

   9 = Other

   10  = Unknown

11.  What was the gender of the claimant?

   1 = Male

   2 = Female

   3 = Unknown

12.  What was the date of birth of the claimant or age of the claimant at the time of the accident?
____________

13.  Was the claimant an adult or a dependent child?

   1 = Adult

   2 = Dependent child

14.  What was the marital status of the claimant at the time of the accident?

   1 = Married

   2 = Single

   3 = Widowed

   4 = Divorced/Separated

   5 = Unknown

15.  How many vehicles were involved in the accident?
____________

16.  What type of vehicle was the claimant driving?

   1 = Car

   2 = Truck

   3 = Van

   4 = Motorcycle

   5 = Bus

   6 = Snow vehicle

   7 = ATV

   8 = None (passenger, pedestrian, bicyclist)

   9 = Unknown

17.  What type of vehicle was the insured driving?

   1 = Car

   2 = Truck

   3 = Van

   4 = Motorcycle

   5 = Bus

   6 = Snow vehicle

   7 = ATV

   8 = Unknown

18.  What was the insured’s degree of fault?
____________%

19.  What was the claimant’s degree of fault?
____________%

20.  Where did the accident occur?

   1 = Ontario

   2 = Québec

   3 = Other jurisdiction in Canada

   4 = U.S.A

21.  What was the date of the accident?
___________ (YYYYMMDD)

22.  What time did the accident occur?

   1 = 12:00 AM

   2 = 1:00 AM

   3 = 2:00 AM

   4 = 3:00 AM

   5 = 4:00 AM

   6 = 5:00 AM

   7 = 6:00 AM

   8 = 7:00 AM

   9 = 8:00 AM

   10 = 9:00 AM

   11 = 10:00 AM

   12 = 11:00 AM

   13 = 12:00 PM

   14 = 1:00 PM

   15 = 2:00 PM

   16 = 3:00 PM

   17 = 4:00 PM

   18 = 5:00 PM

   19 = 6:00 PM

   20 = 7:00 PM

   21 = 8:00 PM

   22 = 9:00 PM

   23 = 10:00 PM

   24 = 11:00 PM

   25 = Unknown

23.  How was the accident classified according to the police report?

   1 = Fatal injury

   2 = Non-fatal injury

   3 = PD only

   4 = Non-reportable

   5 = Other

   6 = No Police Report

24.  What was the description of the injuries according to the police report?

   1 = None

   2 = Minimal

   3 = Minor

   4 = Major

   5 = Fatal

   6 = No Police Report

 

Claim Settlement Information

25.  Accident Report Date

   What date did the insured report the accident to your company?
_______________ (YYYYMMDD or “N/A” if not applicable)

   What date did an injured third party or their legal representative report the accident to your company?
_______________ (YYYYMMDD or “N/A” if not applicable)

26.  On what date was a bodily injury reserve opened?
_______________ (YYYYMMDD)

27.  Who made the first verbal or written offer to settle?

   1 = Claimant

   2 = Claimant’s legal representative

   3 = Your company

   4 = Neither

   5 = Unknown

 

28.  What was the date of first verbal or written offer to settle?
_______________ (YYYYMMDD)

29.  What was the date of the first indemnity payment made to the claimant?  (If there is only one payment made to the claimant, consider it the first and final/full payment for this question.)
_______________ (YYYYMMDD)

30.  What was the amount of the first indemnity payment made to the claimant?  (If there is only one payment made to the claimant, consider it the first and final/full payment for this question.)
____________________

31.  What was the amount of the initial best estimate case reserve established for the claimant?
____________________

32.  Prior to settlement, was there a risk of exposing the policyholder to liability in excess of coverage (based off of actual realistic assessment or best judgement rather than a legal representative’s pleadings/or statement of claim amount)?

   1 = Yes

   2 = No

   3  = Unknown

 

33.  Was the SABS insurer involved in concurrent settlement negotiations?

   1 = Yes

   2 = No

   3  = Unknown

 

34.  What was the date that the BI claim for this specific claimant was closed?  (This is the final closing date in cases where the file was reopened.)
_______________ (YYYYMMDD)

   If the claim is still open, what is the estimated outstanding remaining dollar liability for the claim?_______________________

 

Claimant Employment Information

35.  What was the employment status of the claimant at the time of the accident?

   1 = Employed full time

   2 = Employed part time

   3 = Homemaker [2]

   4 = Student

   5 = Pre-school age

   6 = Retired

   7 = Unemployed

   8 = Other

   9 = Unknown

 

36.  What type of employment was the claimant involved in at the time of the accident?

   1 = Managerial/professional

   2 = Clerical

   3 = Manual

   4 = Self-employed

   5 = None

37.  What was the gross weekly income of the claimant at the time of the accident?  (If unemployed, enter “0”.)
____________________

38.  How much time did the claimant lose from work from the injury to the date of the settlement? (If less than one month provide the number of days, if greater than one month provide the number of months)
____________________ (Please specify if days or months)

39.  Was loss of competitive advantage claimed by the claimant?

   1 = Yes

   2 = No

   3  = Unknown

 

Injury Information

40.  What date was the injury reported to your company?
_______________ (YYYYMMDD)

41.  Who first reported the injury to the insurer?

   1 = Insured

   2 = Claimant

   3 = Claimant’s legal representative

   4 = Other

   5 = Unknown

 

42.  What was the condition of the claimant as a result of the accident?

   1 = Fatality (at the scene of the accident)

   2 = Injured

   3 = Not Injured

43.  Type of injury claimed (Select all that apply.)

   No injury

   Death

   Psychological impairment

o Anxiety

o Depression

o Post Traumatic Stress Disorder (PTSD)

o Other

   Mental impairment

   Quadriplegia, Paraplegia, Hemiplegia, or other spinal injury

   Head

o Permanent brain injury

o Fracture

o Concussion

o Post-Concussion Syndrome

o Scalp Avulsion/Laceration

o Other Head/Brain Injury

   Face

o Fracture

o Laceration with scar

o Laceration with no scar

o Jaw Fracture

o Loss of Teeth

o Temporomandibular Joint Dysfunction (TMJ)

o Tooth/Jaw Other Injury

   Neck

o Mild strain, sprain or soft tissue injury

o Moderate strain, sprain or soft tissue injury

o Severe strain, sprain or soft tissue injury

o Other

   Back

o Mild strain, sprain or soft tissue injury

o Moderate strain, sprain or soft tissue injury

o Severe strain, sprain or soft tissue injury

o Other

   Chest and Ribs

o Fracture

o Other

   Internal

o Internal organ injury where surgery was required

o Other

   Shoulder

o Strain/Soft tissue

o Fracture

o Laceration

o Other

   Arm

o Fracture

o Loss of one arm

o Loss of both arms

o Laceration

o Other arm injury

   Elbow

o Fracture

o Other

   Wrist and Hand

o Fracture of Wrist or Hand

o Loss of one hand

o Loss of both hands

o Laceration of wrist or hands

o Loss of fingers

o Strain of the wrist or finger

o Other wrist or hand injury

   Pelvis and Hip

o Fracture

o Other

   Leg

o Fracture

o Loss of one leg

o Loss of both legs

o Laceration

o Other leg injury

   Knee

o Soft Tissue/Sprain/Strain

o Fracture

o Other

   Ankle and Foot

o Fracture of ankle or foot

o Loss of one foot

o Loss of both feet

o Sprain

o Laceration of ankle or foot

o Other ankle or foot injury

   Burns

   Fibromyalgia

   Chronic pain

   Subluxation

   Permanent loss of a sense (taste, smell, sight, touch or hearing)

   Other disfigurement

   Other Injury

44.  Among those injuries checked, indicate which, in your judgment, was the most serious injury?
___________________

45.  Which injury was the most expensive? (Medical treatment costs) 
___________________

Claim Payment Information

46.  What are the total amounts of gross payments made to the claimant?
_____________________

47.  What were the punitive damages awarded?
_______________

48.  Breakdown of all loss amounts, including claim payments, settlement amounts and trial awards.

   Special damages

o Loss of Income (net of collateral sources): _______________________

o Other income loss (net of collateral sources): _______________________

o Medical & rehabilitation (net of collateral sources): _____________________

o Housekeeping: ____________________

o Family Law Act: ____________________

o Funeral expenses: ____________________

o Other: ________________________

o Subtotal: ______________________

   General damages

o Non-pecuniary:______________________

o Family Law Act: ______________________

o Loss of future employment income: _______________________

o Future care: ________________________

o Gross up for tax: _____________________

o Fund management (to handle settlement amount): ___________________

o Subtotal: _______________________

   Partial Indemnity Cost (Party and party): ______________________

   Prejudgment interest: ________________

 

   Disbursements: ________________

 

49.  Was the non-pecuniary deductible applied?

   1 = Yes

   2 = No

50.  Family Law Act Claims (if FLA payment was paid as a lump sum, allocate to individual categories using your best judgment):

   Amount paid to spouse: _______________________

o Deductible Applied (Yes/No): ____________

   Children

o Number of claimants: ___________________

o Number of claimants paid: ________________

o Amount paid: __________________

o Deductible Applied (Yes/No): ____________

   Grandchildren

o Number of claimants: ___________________

o Number of claimants paid: ________________

o Amount paid: __________________

o Deductible Applied (Yes/No): ____________

   Parents

o Number of claimants: ___________________

o Number of claimants paid: ________________

o Amount paid: __________________

o Deductible Applied (Yes/No): ____________

   Grandparents

o Number of claimants: ___________________

o Number of claimants paid: ________________

o Amount paid: __________________

o Deductible Applied (Yes/No): ____________

   Siblings

o Number of claimants: ___________________

o Number of claimants paid: ________________

o Amount paid: __________________

o Deductible Applied (Yes/No): ____________

   Other

o Number of claimants: ___________________

o Number of claimants paid: ________________

o Amount paid: __________________

o Deductible Applied (Yes/No): ____________

51.  Breakdown of Internal/External Expenses

   Insurer’s outside counsel: __________________

   Insurer’s in-house counsel: __________________

   Independent adjuster: _________________

   Defence medical: ___________________

   Other expert (i.e. private investigators, surveillance, accident reconstruction): ___________________

   Other claim expenses (i.e. court reports, police reports, other costs that can be allocated to the claim): ______________________

52.  Were Statutory Accident Benefits paid?

   1 = Yes

   2 = No

   3  = Unknown

 

53.  Has the claimant been determined to be catastrophically impaired for the purposes of the accident benefits coverage?

   1 = Yes

   2 = No

   3  = Unknown

 

54.  Was a future care plan submitted by the claimant?

   1 = Yes

   2 = No

   3  = Unknown

 

55.  Amount of Statutory Accident Benefits paid:

   Medical: _____________

   Rehabilitation: ____________

   Attendant Care: _____________

   Caregiver: ______________

   Funeral: ______________

   Death: ______________

   Housekeeping and Home Maintenance: ____________________

   Income replacement: ________________

   Dependant care: __________________

   Non-earner: __________________

   Education: __________________

   Other: __________________

   Total: _______________________

   Total deducted from BI payment: __________________

56.  Were salary continuance benefits paid by the employer?

   1 = Yes

   2 = No

   3  = Unknown

 

57.  Amount of salary continuance benefits paid by employer:

   Percentage of salary paid under sick leave: ______________

   Amount of salary paid under sick leave: _______________

   Percentage of salary paid under short term disability: ______________

   Amount of salary paid under short term disability: _______________

   Percentage of salary paid under long term disability: ______________

   Amount of salary paid under long term disability: _______________

   Total: _____________________

   Total deducted from BI payment: ____________________

58.  Were government benefits received by claimant (EI, CPP, Worker's compensation, or other)?

   1 = Yes

   2 = No

   3  = Unknown

 

59.  Amount of government benefits paid:

   EI:  __________________

   CPP: __________________

   Worker’s compensation: ___________________

   Other: __________________

   Total: ___________________

   Total deducted from BI Payment: _________________

Claim Process Information

60.  When was the first medical report received by your company?
________________(YYYYMMDD)

61.  Did the claimant have legal representation?

   1 = Yes

   2 = No

   3  = Unknown

 

62.  Was a legal action commenced?

   1 = Yes

   2 = No

   3  = Unknown

 

63.  Was the claimant examined for discovery?

   1 = Yes

   2 = No

   3  = Unknown

 

64.  Was the case pre-tried?

   1 = Yes

   2 = No

   3  = Unknown

 

65.  Did the case go to trial?

   1 = Yes

   2 = No

 

66.  Was the case tried by a jury?

   1 = Yes

   2 = No

   3 = Unknown

 

67.  What was the net verdict or net settlement amount compared to the last settlement offer or last demand (whichever came last)?

   1 = Less than last offer

   2 = Equal to last offer

   3 = Larger than last offer

   4 = Less than last demand

   5 = Equal to last demand

   6 = Larger than last demand

   7 = No settlement offer or demand

   8 = Unknown

 

68.  Was there an appeal?

   1 = Yes

   2 = No

   3  = Unknown

 

69.  If appealed, was the case appealed by the plaintiff?

   1 = Yes

   2 = No

   3 = No appeal

 

70.  Was the case settled? If so, when?

   1 = Before legal action commenced

   2 = After legal action commenced but before examination discovery

   3 = After examination for discovery but before pre-trial

   4 = At pre-trial or as an immediate consequence of pre-trial

   5 = Between pre-trial and date action called for trial

   6 = At trial

   7 = Not settled

 

71.  Was an independent medical exam conducted?

   1 = Yes

   2 = No

   3  = Unknown

 

72.  Was the independent medical exam conducted before or after legal action commenced?

   1 = Before legal action commenced

   2 = After legal action commenced

   3 = No independent medical exam conducted

73.  Did your company require a statement under oath from the claimant?

   1 = Yes

   2 = No

   3  = Unknown

 

74.  Was the claim paid under a structured settlement?

   1 = Yes

   2 = No

   3 = Unknown

 

75.  Was the structured settlement entered into voluntarily or required by the court?

   1 = Voluntarily

   2 = Required by court

   3 = No structured settlement

   4 = Unknown

76.  Other than Partial Indemnity Cost (Party and party) (48), what is the total of all payments related to the structured settlement included in the total amounts of gross payments (46)?
____________________

77.  What were the brokerage and other fees related to structured settlement?
____________________

78.  (non-FLA claims only:) Did the claimant’s injuries overcome the tort threshold?

   1 = Yes

   2 = No

   3 = FLA Claim

 

79.  How was the tort threshold overcome?

   1 = Death

   2 = Permanent serious disfigurement

   3 = Permanent serious impairment of an important physical function

   4 = Permanent serious impairment of an important mental function

   5 = Permanent serious impairment of an important psychological function

   6 = Threshold not overcome

   7 = Unknown



Appendix 2

Ontario Liability Claim Study Injury Descriptions



Closed Automobile Insurance Third Party Liability Bodily Injury Claim Study in Ontario

Injury Descriptions – Developed from Newfoundland claim study injury definitions

   No injury

   Death

   Psychological impairment - This will include such diagnoses as post-traumatic stress disorder, depression, anxiety, insomnia.

o Anxiety

o Depression

o Post Traumatic Stress Disorder (PTSD)

o Other

   Mental impairment

   Quadriplegia, Paraplegia, Hemiplegia, or other spinal injury - Quadriplegia includes complete and incomplete. Incomplete quadriplegia refers to partial motor and sensory loss. Complete quadriplegia refers to full motor and sensory loss. Paraplegia refers to paralysis of the legs and lower part of the body. Hemiplegia refers to paralysis of one side of the body.

   Head

o Permanent brain injury - This condition occurs as the result of a head injury. It is the result of physical damage to the brain tissue. In this condition there is permanent impairment in the mental and emotional processes and their functioning. It imposes restrictions on the client’s ability to carry out the activities of daily living.

o Fracture

o Concussion - This refers to a head injury where there is post-traumatic loss of consciousness lasting less than 24 hours (usually much less). The individual is rarely unresponsive. This injury is of minor significance, although there may be minor deficits in memory, concentration, attention, and perception lasting up to three months.

o Post-Concussion Syndrome - A constellation of symptoms that affects up to 50% of individuals following a mild head injury. These symptoms last beyond three months of the injury. Symptoms include persistent headaches, fatigue, balance disturbances, irritability, impaired memory and concentration, etc. The cause of the condition is unknown and it may persist for months or years. It does not respond well to any kind of treatment.

o Scalp Avulsion/Laceration

o Other Head/Brain Injury

   Face

o Fracture

o Laceration with scar

o Laceration with no scar

o Jaw Fracture

o Loss of Teeth

o Temporomandibular Joint Dysfunction (TMJ) - This may impede chewing, affect speech, cause lower facial deformity, and produce pain.

o Tooth/Jaw Other Injury

   Neck (choose the most severe applicable category) - This may be referred to using the following terms: whiplash, whiplash associated disorder (WAD), a cervical strain, soft tissue injury (STI), etc. Neck strains/sprains will be further broken down into three categories dependent on the severity of the symptoms and signs.

o Mild strain, sprain or soft tissue injury - This includes WAD(Whiplash Associated Disorder) I and II. Neck symptoms only (WAD I) - Symptoms may include complaints of pain in the neck (one or both sides), stiffness, and tenderness. There are no physical signs. Symptoms may be delayed hours or to the next day. Resolution is expected to start in days. Recovery to usual activities is usually in six weeks or less.

Neck symptoms and musculoskeletal signs (WADII) - Symptoms usually include pain in the neck, one or both sides, and there may be pain in the arms. These start within minutes to a few hours. Signs include muscle spasm and /or decreased range of motion. X-rays may show spasm. Resolution may linger for months, but most resolve in ninety days.

o Moderate strain, sprain or soft tissue injury - Neck complaints and neurological signs (WAD III) - These may include absent reflexes, weakness and sensory deficits. Symptoms usually start immediately. Radiating shoulder and arm symptoms soon follow. Neurological deficits are found on examination. These symptoms may linger for months and there may be recurrences or chronic symptoms. Medical aid treatment may be required for up to one year.

o Severe strain, sprain or soft tissue injury - Neck complaints and fracture or dislocation (WAD IV) - In this case there is a fracture without spinal cord injury. Symptoms can start instantly. Neck weakness can be found. Radiation of symptoms to shoulder and arms are variable. The eventual outcome is variable ranging from complete recovery to long-term complications.

o Other

   Back (choose the most severe applicable category) - This includes injuries to the thoracic spine (upper back) or to the lumbar spine (lower back). Common terms to describe these injuries include soft tissue injury (STI), mechanical back pain, musculoligamentous injury, etc. Again we further divide this group into three categories according to the severity of the injury.

o Mild strain, sprain or soft tissue injury - Back symptoms with or without musculoskeletal signs - Symptoms include complaints of pain in the back (upper and/or lower) with or without stiffness or tenderness. There may be buttock and/or leg pain. Symptoms may start within minutes or be delayed for hours or even the next day. Physical exam may show decreased range of motion and spasm. Resolution may start within days with most returning to usual activities in 90 days.

o Moderate strain, sprain or soft tissue injury - Back complaints and neurological signs. This may include absent reflexes, weakness and/or sensory disturbances. Symptoms usually start immediately. Pain often radiates below the knee into the calf and/or foot. Symptoms may linger for months and there may be recurrences or chronic symptoms. Treatment may be required for up to a year. This will include disc injuries. Terms used in diagnoses include sciatica, nerve root impingement, disc prolapse, etc.

o Severe strain, sprain or soft tissue injury - Back complaints and fracture or dislocation - In this case there is a fracture without spinal cord injury. Symptoms can start instantly. There may or may not be disc injury or nerve root impingement. Radiation of symptoms to the legs is variable. Again the eventual outcome is variable ranging from full recovery to long-term complications.

o Other

   Chest and Ribs

o Fracture

o Other

   Internal - e.g. lung, heart, reproductive organs, loss of spleen, gastrointestinal injury associated with loss of bowel, kidney damage

o Internal organ injury where surgery was required

o Other

   Shoulder

o Strain/Soft tissue - This includes rotator cuff strains and tears, acromio-clavicular strains, shoulder dislocations, frozen shoulder, bursitis, tendonitis, etc.

o Fracture

o Laceration

o Other

   Arm

o Fracture

o Loss of one arm

o Loss of both arms

o Laceration

o Other arm injury

   Elbow

o Fracture

o Other

   Wrist and Hand

o Fracture of wrist or hand

o Loss of one hand

o Loss of both hands

o Laceration of wrist or hands

o Loss of fingers

o Strain of the wrist or finger

o Other wrist or hand injury

   Pelvis and Hip

o Fracture

o Other

   Leg

o Fracture

o Loss of one

o Loss of both legs

o Laceration

o Other

   Knee

o Soft Tissue/Sprain/Strain - This may include injuries such as meniscal tears, collateral ligament tears/strains, cruciate ligament tears, patellofemoral syndrome

o Fracture

o Other

   Ankle and Foot

o Fracture of ankle of foot

o Loss of one foot

o Loss of both feet

o Sprain of ankle or foot

o Laceration of ankle or foot

o Other ankle or foot injury

   Burns

   Fibromyalgia - A chronic musculoskeletal disorder of uncertain cause characterized by chronic widespread pain and multiple tender points.

   Chronic pain - A term given to longstanding complaints of trauma-induced discomfort and pain that have persisted beyond the expected healing times and have resisted more conservative and traditional health care intervention strategies. Pain has lasted at least six months.

   Subluxation

   Permanent loss of a sense (taste, smell, sight, touch or hearing)

   Other disfigurement - This may be caused by the injury itself or be the result of surgery

   Other Injury

 



Appendix 3



Error Checks Conducted

Errors

1.      Numerical amounts not entered in fields where amounts expected (e.g.: payment amounts, limits)

2.      Incorrect entries in date of birth or age field

3.      Duplicate entries

4.      General amount total not equal to sum of the individual general categories

5.      Special amount total not equal to sum of the individual special categories

6.      Inconsistent injury entries (i.e. on box indicates no injury but another injury type is checked)

7.      No outstanding liability entered when the claim was designated as open

Missing Information

If any of the following information was missing in a record, the record was returned to the company for completion

1.      Accident date

2.      Accident location

3.      Claim number

4.      Claim type

5.      Claimant condition

6.      Claimant number

7.      Completed by

8.      Date of first payment

9.      Date occurrence was closed

10.  Gross payments

11.  Most costly injury

12.  Most significant injury

13.  First payment

14.  Policy limit

15.  Threshold

16.  Tort

[1] Road Safety Program Office, Safety Policy & Education Branch, Ministry of Transportation “Ontario Road Safety Annual Report 2005.” p. 36.

[2] A person who manages a household as one’s main daily activity