Access to Claimant Personal Health Information

 
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Access to Claimant Personal Health Information


  1. Can an insurer request personal health information from providers in order to adjudicate a claim?
  2. What authority do FSCO Senior Compliance Officers have to access a claimant's personal health information when conducting on-site examinations?

Can an insurer request personal health information from providers in order to adjudicate a claim?

Yes, but only where such information is reasonably necessary and the claimant to whom the information relates has provided consent. 

 

Section 46.2 of the Statutory Accident Benefits Schedule – Effective September 1, 2010 (SABS) permits an insurer to request any information in order to determine its liability for payment, and this may include claimant personal health information.

 

However, the SABS requires the insurer to act reasonably and request only the information necessary in order to determine its liability for payment. This provision does not grant an insurer blanket access to all clinical records and/or notes related to a particular claimant. In making such requests, insurers should ensure that the claimant has provided the proper consent.

 

What authority do FSCO Senior Compliance Officers have to access a claimant's personal health information when conducting on-site examinations?

In order to ensure that service providers are in compliance with their licence obligations and meeting the specific requirements of Ontario Regulation 90/14, FSCO Senior Compliance Officers (SCOs) must have access to the service provider’s completed claims forms submitted through HCAI (OCF-18, OCF-23, and OCF-21).  

 

The potential disclosure of any personal health information during the course of an examination is for the lawful purpose of conducting a compliance examination, authorized under section 443(1) of the Insurance Act.

 

It should be noted that, during the examination, the compliance items FSCO examiners are looking for generally do not require the review of the portions of the forms that might contain personal health information. In addition, FSCO SCOs are not collecting, recording, or removing this information from the premises. The exception may be where an SCO believes there is fraudulent activity and that the forms contain false or inflated information about an individual’s injuries.

 

Like all Ontario Public Service employees, FSCO SCOs must, pursuant to the Public Service Ontario Act, 2006, take an oath of office, and swear and affirm that they will not disclose or share any information or document that comes into their knowledge or possession except as required by law.

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