DAC Communiqué - June/July 1998

The Information Communiqué was developed to provide stakeholders with an update on the activities of the DAC Committee. This issue reviews the DAC complaint process and recent arbitration decisions that comment on DAC reports, and provides updates on the Revised OCF-11, DAC Assessor Practice Summary Form and an update on the development and revisions of assessment protocols.

DAC Complaint Process

The Minister's Committee on the Designated Assessment System (the DAC Committee) is responsible for overseeing and providing direction on the process that the Ontario Insurance Commission (OIC) staff follow in responding to complaints from claimants and insurers about DACs. All stakeholders should be aware of the complaint process.

All complaints concerning DACs should be directed to the OIC Accident Benefits Analysis Unit (ABAU), in writing.

How it Works

The ABAU staff, under the direction of the DAC Committee, reviews all complaints to determine whether the issues relate to the conduct of a DAC and compliance with the legislation or guidelines. The ABAU can only deal with a DAC's non-compliance with the legislation or the guidelines. If the complaint involves a disagreement with the outcome of a DAC report, the complainant is referred to Dispute Resolution at the OIC. If the complaint is about the conduct of a health professional, the complainant is directed to the appropriate regulatory professional college. If the complaint is about the business practices of an insurance company, the complainant is directed to the insurance company's Ombudsman representative.

If the complaint is of a general nature or it requires clarification of the Statutory Accident Benefits Schedule (SABS), the ABAU responds directly without requiring the DAC to prepare a response. If the complaint is about a specific DAC, the ABAU informs the complainant that the issue is being investigated and that the DAC in question has been asked to respond. The ABAU requires DACs to respond directly to the complainant and to provide the ABAU with a copy of the response for review. The DAC Committee has directed the ABAU to treat arbitration decisions which comment on the performance of a DAC as a written complaint.

The Objective

The objective of this complaint process is to rectify problems rather than to sanction DACs. If the ABAU, in conjunction with the DAC Committee, concludes after a review of the DAC's response to the complaint, that the DAC has failed to comply with the SABS or guidelines, the ABAU works with the DAC to try to correct the problem. Depending on the nature of the complaint and the DAC's response, the DAC Committee may require the DAC to follow up with a progress report on their compliance within a specific time frame.

 

The Result

If a DAC has repeatedly been unable or unwilling to comply with the SABS or guidelines, the ABAU will raise the matter with the DAC Committee. The DAC Committee may wish to meet with the DAC to outline the consequences of non-compliance, including the removal of the DAC from the Roster. The DAC Committee has the responsibility of approving and removing DACs from the Roster.

DAC Best Practices

Recently, arbitrators at the OIC have commented on DAC reports in the course of their decisions about a claimant's entitlement to statutory accident benefits.

The DAC Committee hopes that by providing examples of how arbitrators have used DAC reports in the decision-making process, DACs will be encouraged to use best practices in completing their assessments.

In OIC File A96-001160 the disability DAC report could not be relied upon because the assessor did not adequately explain the basis for the conclusion about the claimant's abilities. The report did not set out the claimant's essential tasks (of a general labourer), nor was it clear that the assessor considered the Job Analysis Worksheet which set out the claimant's specific duties.

In OIC File A96-001554, the arbitrator found the disability DAC report to be unreliable, and placed no weight on it. The assessor stated that two of the tests performed in the examination suggested "inconsistencies" and that "malingering tests were positive and repeatable over three attempts", but he did not describe the tests and did not reveal how or why he arrived at his conclusions. He also failed to take into account the claimant's work as a home renovator and decorator in reaching his conclusion that the claimant was capable of completing the daily activities in which she was involved prior to the motor vehicle accident.

In OIC File A96-001284, although the disability DAC concluded that the claimant was disabled, the report went on to prognosticate full recovery in 6 to 8 weeks after a work-hardening program. Upon completion of the work-hardening program, benefits were terminated. The claimant requested a further disability DAC assessment, which was refused by the insurer. The arbitrator found the claimant remained disabled and ordered reinstatement of income replacement benefits, plus interest. It should be noted that disability DACs cannot provide a prognosis for recovery or project a period of continued disability.

In OIC File A97-000760, the arbitrator found that the DAC assessor had taken on the role of advocate for the insurer when the assessor wrote to the adjuster that the assessor was trying to write the report "so as to be of maximal benefit when (the claimant) takes you to mediation/arbitration". The arbitrator placed little weight on the disability DAC report.

Copies of the OIC's arbitration and appeal decisions can be accessed through the OIC's website at http://www.fsco.gov.on.ca.

Revised OCF-11 Form (DAC Referral and Summary Report)

A revised OCF-11 Form for use by insurers and DACs has recently been issued. The changes to the form capture information on whether the nearest DAC to the claimant's residence was able to perform the assessment, as well as the nature of the medical and rehabilitation benefit in dispute.
 

DAC Assessor Practice Summary Form

A DAC Assessor Practice Summary Form (Practice Summary Form) has recently been issued. The Practice Summary Form serves two purposes: to assist the ABAU in ensuring that assessors meet the minimum requirements to be placed on the DAC Roster; and, to respond to requests by claimants for information about any assessor on the DAC team performing an assessment.

The Practice Summary Form will streamline the entire process, eliminating missing key information and enabling the ABAU to respond to the DAC with a date-stamped approved document that the DAC can then provide to claimants and insurers as proof that the assessor is on file with the OIC.

Any change in staffing must be reported to the ABAU, with the requisite information provided in the Practice Summary Form.

A General Guideline currently under development will require DACs to send a one-page "DAC Assessor Practice Summary" to the claimant along with the notice of the assessment date. The practitioner's curriculum vitae will be available on request at reasonable photocopy rates.

Assessment Protocols

The DAC Committee has undertaken the task of reviewing, revising and developing a cohesive and comprehensive DAC manual, with input from DACs and other stakeholders.

Consultation on newly developed and revised assessment protocols with DACs and stakeholders has and will occur as part of the development process. This process was established with the recently released Catastrophic Impairment DAC Interim Manual. Consultations with the Residual Earning Capacity DACs and the Medical Rehabilitation DACs have already begun. The DAC Committee is committed to holding stakeholder consultations with Disability DACs and Attendant Care DACs in the development of those manuals as well.

Readers' Corner

We welcome your feedback. Please write to us at:

The Minister's Committee on the Designated Assessment Centre System
c/o The Accident Benefits
Analysis Unit
Ontario Insurance Commission
5160 Yonge Street
17th Floor
North York ON M2N 6L9

June/July 1998

 
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