OCTOBER 2001

DESIGNATED ASSESSMENT CENTRE COMPLAINT MANAGEMENT and DISCIPLINE PROTOCOL

1.0 Introduction

The Minister’s Committee on the Designated Assessment Center (DAC) System (Committee) was appointed by the Minister ofFinance under section7 of the Insurance Act, as amended by Bill 59, the Automobile Insurance Rate Stability Act, 1996.

A subset of the DAC Committee, the Operations Subcommittee, supported by the Automobile Insurance Policy Unit (AIPU) at the Financial Services Commission of Ontario (FSCO), manages complaints related to the DAC System and/or individual DACs.

2.0 Mandate of the DAC Committee

The DAC Committee has a number offunctions as specified by the provisions of the legislationand by assignment of the Minister of Finance. Specifically, the DAC Committee is to:

C appoint DACs to a roster for the purposes of the Statutory Accident Benefits Schedule; C specify the types of impairments that each DAC is authorized to assess; C specify the types of assessment that each DAC is authorized to conduct; C ensure that the number of DACs by type of assessment, type of impairment and location meet the

needs of the insurer and claimants; C establish and maintain operational procedures and guidelines dealing with assessments conducted

by DACs; C establish and implement assessment protocols for use by DACs when conducting assessments; C establishand implement a systemforevaluating and monitoring the performance of the DAC system

as well as individual DACs; C establish and implement a process to deal with complaints from insurers and claimants regarding

DACs that fail to conduct assessments as set out in the operational procedures and guidelines and assessment protocols;

C establish a fee schedule for DAC assessments; C direct research for the purpose of establishing treatment protocols for specific injuries sustained in

automobile accidents; C identify ongoing educational needs of DACs and develop programs to address those needs; and C recommend persons to conduct arbitrations under the Insurance Act to the Commission.

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3.0 Role of the Operations Subcommittee and AIPU

The Operations Subcommittee is responsible for overseeing and providing direction on the process that is to be followed by AIPU staff in responding to complaints from claimants and insurers about DACs.

The AIPU:

C reviews all written complaints; C reviews the conduct, capability and/or service processes of DACs in situations where the Operations

Subcommittee feels this is appropriate and in the best interests of the public.

The Operations Subcommittee:

C guides AIPU staff in determining the level of review required for specific complaints;C assigns, when necessary, DAC Committee representatives to complaint review teams;C takeswhatevercorrective action, or imposes suchconditions, requirements or sanctions onDACs,as it feels

are appropriate including the removal of DACs from the roster where necessary; C guides AIPU staff in the implementation of complaint decisions and follow-up actions; C monitors the quality of the complaint management process; and, C provides a regular update to the DAC Committee on the nature and frequency of complaints, as well as

follow-up actions and sanctions.

4.0 What Kinds of Complaints Are Reviewed?

Complaints are reviewed to determine if DACs have conducted assessments in the manner that is set out in the Insurance Act, Statutory Accident Benefits Schedule, DAC system guidelines and assessment protocols. If additionalconcerns are identifiedin the course ofa review, the Operations Subcommittee maygo beyond the specific issues raised by the complaint to address larger, systemic issues. Additionally, AIPU has been directed to treat arbitration decisions that comment on the performance of a DAC as a writtencomplaint if that performance is non­compliant with legislation, DAC system guidelines or assessment protocols.

AIPU has been instructed to review complaints related to:

Conduct Requirements Specific to the DAC System

C Compliance withprinciples of neutrality and unbiased behaviour both perceived and actual throughout the entire DAC assessment process including DAC reports.

C Compliance with general guidelines that promote transparency of the assessment process (e.g., guidelines for use of surveillance material).

C Compliance with operating guidelines. C Compliance with conflict of interest rules.

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Capability Requirements

C Compliance withsystem-specific humanand physicalresource standardsgiventhe typeofassessments that the DAC is authorized to conduct.

4.0 Types of Complaints (Continued)

Service Requirements C Compliance with guidelines for Intake/ Reporting C Compliance with assessment protocols specific to DAC type.

The AIPU will only review complaints against current guidelines. If the issue(s) arising from a complaint have been resolved by new guidelines, then complainants will be advised of current DAC practices and no second level review will be conducted.

5.0 What Kinds of Complaints Are Not Reviewed?

The DAC Committee cannot instruct the Operations Subcommittee or AIPU to review complaints outside its jurisdiction. A comprehensive screening process has been established to identify and redirect, in a timely manner, those complaints that fall outside the jurisdiction of the DAC Committee. The following complaints may be re­directed by AIPU staff:

Complaints that Relate to the Practices of Insurance Company Staff Relative to the DAC System

These are redirected to the Ombudsman Liaison Officer at the claimant’s insurance company. Every company has appointed an officer to act as liaison and address consumer complaints. If the complainant reports that her/his complaint is still unresolved afterdealingdirectly withthe insurance company, he/she willbe directed to the Insurance Ombudsman.

The Insurance Ombudsman deals withwrittencomplaints about automobile, property and casualty, life and health, and travel insurance. The Insurance Ombudsman will make recommendations to the Superintendent of FSCO to inquire into a complaint if it appears, for example, that an insurer has engaged in a business practice that is non­compliant with the provisions of the Insurance Act and/or the Statutory Accident Benefits Schedule.

Complaints that Relate to the Performance or Conduct of Health Care Professionals

Complaints that relate to the continuing competence, license, scope ofpractice, professionalconduct and standards ofpractice of individual, regulated healthprofessionals are directed to relevant regulatory colleges. As specified by the provisions of the Regulated Health Professions Act, regulatory colleges are responsible for investigating all written complaints that are received about their individual members.

Complaints Concerning the Outcome of a DAC Report

When complaints involve entitlement to or the amount or duration of automobile insurance accident benefits (i.e., the dispute relates to the conclusions reached in the DAC assessment) AIPU staff can provide information about a claimant’s or insurer’s right to pursue dispute resolution through the Mediation Unit of the Dispute Resolution

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Services at FSCO. (NB. This type of complaint will not be sent to the DAC Committee for review).

6.0 “Fairness” Standards For Managing DAC System Complaints and Sanctions

The DAC Committee has adopted “fairness”standards to serve as a reference guide for the DAC Committee when reviewing complaints, determining follow-up actions and/or sanctions, and to ensure that DACs, against

6.0 “Fairness” Standards For Managing DAC System Complaints and Sanctions (continued)

whom complaints are made, will understand the process. These standards are also used to govern the internal procedures used during the complaint management process by the Operations Subcommittee and AIPU staff:

(a) DACs should be provided with ongoing, accurate information about the current conduct, capability and service requirements (including intake and reporting guidelines and assessment protocols) that will be used during complaint review.

(b) DACsshould be informed about the criteria that willbe used to guidedecisions about follow-up actions and sanctions in the management of complaints.

(c) DACs should be given written notice within 5 business days after determining that a complaint will be formally reviewed.

(d) DACs will be given a copy of the complaint or a synopsis of the complaint, and any other relevant information, and an opportunity to respond.

(e) If desired, the DAC and/or complainant should be able to present his/her point of view in writing, and respond to facts presented by others. This will be considered during the complaint review process. The Operations Subcommittee may request a face to face meeting with the DAC to hear their point of view. DACs may request a face to face meeting with members from the Operations Subcommittee. These requests willbe considered ona case by case basis. In some cases where the complainant is the claimant, the insurer may be asked for their point of view and visa versa.

(f) All important facts related to the complaint should be obtained, documented in the complaint record, and considered before the Operations Subcommittee arrives at a decision. If other legislation governs this provision, they must be followed.

(g) The DAC Committee and AIPU must protect the confidentiality of information in the complaint record during all stages of review and decision-making.

(h) Decisions should be reached objectively, withdue respect for relevant facts, and without bias. Care should be taken to require and use only that information which is relevant to the decision.

(i) Complaint management policies and procedures should be followed consistently. Any deviation from the norm should be documented, justified and explained.

(j) The Operations Subcommittee’sdecisionshould be provided to the DAC and both the claimant and insurer

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in writing.

(k) If the Operations Subcommittee’s decision is to remove the DAC from the roster, the DAC will have 15 days , after it receives the Operations Subcommittee decision, to register an appeal to the full DAC Committee. (See section 9.0 “Appeal Process” for details).

(l) A proper record of the investigationand decisions reached should be kept by the AIPUina secure location for 7 years.

6.0 “Fairness” Standards For Managing DAC System Complaints and Sanctions (continued)

(m) The entire process should be completed within 6 – 8 weeks of receiving a complaint. Given variation in the complexityofcomplaints and in the levelof review that maybe required, informationconcerning the amount of time the process is expected to take should be provided to all parties at the outset and noted in the complaint record. Any delays should be explained.

(n) Accommodation should be made for new or changed circumstances during delay including an opportunity for the DAC and complainant to provide further information.

The “fairness” standards are based on the recognition of a duty to provide “procedural fairness” that ensures the decisions of “decision-making bodies” are arrived at through a fair process and ensures that the process takes into account the degree of seriousness of the complaint.

7.0 The Complaints Process Flow (Figure #1 (attached) provides an overview of the complaint management process.)

All complaints concerning DACs must be directed to the AIPU in writing. Once the complaint has been recorded and assigned to an AIPU staff member, complainants are contacted by telephone within 5 business days by AIPU staff to confirmthe receipt of the complaint and gather additional information that may assist the first level screen. If the AIPUdetermines that the complaint is within the jurisdiction of the DAC Committee, the level of review and the nature of involvement of the Operations Subcommittee are determined. The following criteria guide this decision process:

C Nature of the complaint (i.e. compliance issue related to system-specific conduct requirements, physical and human resource capability requirements, administrative guidelines and protocols and/or clinical protocols)

C Complexity of the complaint (i.e., multiple issues); and,

C Past experience of the DAC (i.e., previous compliance issues).

Where appropriate, complaints are managed byAIPUstaff inconsultationwiththe Operations Subcommittee. Staff provide updates to the Operations Subcommittee about the status of complaints being managed. In more complex or serious complaints, the Operations Subcommittee mayassign additionalmembers of the DAC Committee and the

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AIPU to become of the Operations Subcommittee complaint review team. Members will be selected according to the nature of the complaint and level/type of review that will be required. Conflicts of interest may be identified and they may limit the participation of some Committee members in participating in the review of some complaints.

Written acknowledgment and information about the complaint management process is provided to the complainant within 7 business days of complaint receipt. This information is also provided to the DAC within the same time frame.

The complaint review process is tailored to fit the nature and complexity of the complaint as well as the kind of information that is required.

For example, in a first-time complaint related to a delayin the distributionof the discharge report beyond the 14-day requirement, AIPU staff may directly contact the DAC and ask for a response. AIPU staff may

7.0 The Complaints Process Flow (Continued)

explain the guideline and its rationale, and discuss strategies for avoiding future delays. The complainant will be notified by the AIPUof the reason(s) for delayaswell as the corrective actions that willbe implemented by the DAC.

In the case of a complaint related to physical and human resource capability requirements, a visit to the DAC may be scheduled to support informationcollection. In some cases, the Operations Subcommittee may request a meeting with the DAC to collect additionalinformationthat maybe required to support the complaints review process. In the case of serious misconduct or lack of capability concerns that could result in the removal from the DAC roster, the DAC will be notified and given an opportunity to make an oral representation to the Operations Subcommittee.

The review process is to be completed within 3 – 6 weeks after receipt of the written complaint. Periodic updates are provided to complainants about the status of the review process. Once the review process is completed, the Operations SubcommitteeinconsultationwithAIPUdeterminesappropriate follow-up actions and/or sanctions. Final decisions are shared withthe complainant and the DAC in writing no later than 6 – 8 weeks after complaint receipt except in exceptional circumstances. Follow-up actions and/or sanctions withthe DAC are then implemented.

The AIPU contacts the complainant to access feedback about the complaint management process and closes the file within 8 – 12 weeks after receiving the written complaint. The AIPU is responsible for maintaining comprehensive complaint records and protecting the confidentiality of all information related to complaints.

8.0 Follow-up Actions & Sanctions

The objective of the complaint management process is to resolve the systematic problem that led to the complaintrather than to unnecessarily sanction DACs. The Operations Subcommittee and the AIPU will select from arange of options when determining follow-up actions. Given the nature and complexity of the complaint, and thesupport required by the DAC, AIPU staff may:

C provide education (i.e., at both the DAC level and for the overall DAC system);C arrange for peer mentoring;C request and monitor corrective action plans with time lines and accountability;C arrange mandatory reporting; and/or,

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C schedule site visits.

Inserious situations that warrant a significant response, the Operations Subcommitteemaydecide to suspend a DAC from the roster immediately or place the DAC on probation. In the later case, written notification and the terms of the probation would be provided to the DAC. Adequate time would be provided for the DAC to meet the terms of the probation.

If the DAC fails to meet the terms ofprobation, the Operations Subcommittee will suspend the DAC fromthe roster and notify the DAC Committee. The DAC would then be provided with the decision and the reasons for the decision in writing.

As a means of feedback, the Operations Subcommittee and AIPU may identify trends which require that modifications be made to the existing DAC guidelinesand protocols to provide clarity. The feedback process allows the Operations Subcommittee to identify potentially problematic sections of the Statutory Accident

8.0 Follow-Up and Sanctions (Continued)

Benefits Schedule which will be brought to the attention to the legislation review committee for their consideration.

9.0 Appeal Process for Suspension from Roster

A decision of the Operations Subcommittee to remove a DAC from the roster may be appealed to the full DAC Committee, provided the DAC requests an appeal withing 15 days after receiving the Operations Subcommittee decision. The appeal process will be determined by the DAC Committee but will usually be in the form of an oral submission by the DAC (or their representatives) to a panel of DAC Committee members (minimum of three including a consumer representative) who were not involved in the Operations Subcommittee decision.

10.0 Evaluating the Complaint Management System

A variety of tools are used to monitor and evaluate the complaint management system. A checklist has been developed for use at the case levelto ensure that the review process meets “fairness”standards and isconsistent with policies and procedures. This is particularly important in the case of complex and serious complaints to ensure that the review process will support the decisions and recommendations of the Operations Subcommittee.

Feedback fromcomplainantsis tracked and analyzed to monitor levels of satisfactionwiththe accessibility, timeliness and responsiveness of the system. Feedback from DACs is tracked and analyzed to monitor levels of satisfaction with the accessibility, responsiveness, and remedial support provided by the AIPU and Operations Subcommittee.

Performance against time thresholds is routinely audited. The resources (human and financial) required to support the complaint management system is also routinely analyzed.

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Attachment #1Complaints Management: Process Flow Diagram

Initial Contact & 1st Level

5 business days after

receipt

Written Complaint

Outside Jurisdiction Within Jurisdiction

Contact Complainant & Redirect to Appropriate

Body

Open Complaint File & Second Level Screen

by AIPU to determine level of review required

and nature of DAC

Written Acknowledgement &

Information re process to complainant

Written Notification to DAC & Information re Process

Review Process including information collection

(documentation review,

Written Notification of Decisions to

Claimant & DAC

Decision-Making Process re Follow-up

Actions and/or

Follow-up with

Complainant & File Closure

Monitor and Analyze Trends to evaluate system policies, requirements, guidelines and

protocols

Follow-up with DAC &

Implementation of Remedial

Actions and/or Sanctions

7 business days after

receipt

2-6 weeks after receipt (ongoing

updates with the complainant

6-8 weeks after receipt

72 hours after determination

8-12 weeks after receipt

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