Ontario Regulation 194/11 – Dealing With Suspect Claims Under the SABS

Ontario Regulation 194/11 takes effect July 1, 2011.
The Regulation will allow insurers to challenge claims suspected to be fraudulent.

With respect to clinics, the treatment providers are obligated, upon request, to produce:

1. Any information required to assist the insurer in determining its liability to pay, including providing original documents (treatment confirmation form, treatment and assessment plans, assessment of attendant care needs, etc.).;
2. A statutory declaration as to the circumstances which give rise to invoice; and
3. The contact information for all service providers and proof of their identity.

If the information is not provided within 10 business days, the insurer is not required to pay the invoice and interest will not accrue.

An insured is precluded from applying for mediation if:

1. An application for a benefit has not been submitted within the time limits provided in the SABS or the insured has not notified the insurer about the circumstances giving rise to the claim for benefits;
2. If the insured has not attended a section 44 assessment; and
3. If the issue in dispute relates to the insurer’s denial of liability to pay an amount under an invoice on the grounds that the insurer requested information from a provider under subsection 46.2(1), and the insurer is unable, acting reasonably, to determine its liability for the amount payable under the invoice because the provider has not complied with the request in whole or in part.