Since its introduction in 2014, Ontario’s Health Service Provider (HSP) licensing framework, governed by the Financial Services Regulatory Authority of Ontario (FSRA), has been contentious. Initially created to address fraud in auto insurance billing, this system has evolved into an unnecessary and costly layer of regulation that has failed to demonstrate its value. Instead, it places a considerable burden on healthcare providers, consumers, and FSRA itself. This document advocates for the elimination of the HSP licensing system, detailing how it is redundant, administratively burdensome, fails to prevent fraud, and negatively affects both providers and patients.

HSP licensing is an overreaction that was introduced to ensure accurate invoicing by healthcare providers, creating an entire bureaucratic system that duplicates the regulatory work of healthcare colleges. Given that FSRA’s own data shows little impact, it’s time to eliminate this framework and repurpose the associated resources for more critical functions.

 

HSP Licensing is Redundant

One of the most compelling reasons to abolish the HSP licensing framework is its redundancy. Ontario’s healthcare providers are already subject to stringent regulation through their professional colleges, such as the College of Physiotherapists of Ontario and the College of Chiropractors of Ontario. These regulatory bodies enforce strict professional, legal, and ethical standards, ensuring that practitioners operate within the law and provide high-quality care.

FSRA’s HSP licensing adds another layer of oversight that mirrors what is already regulated by these colleges, without offering any added value. This overlapping regulation creates confusion, with healthcare providers forced to comply with both their professional colleges and FSRA, often encountering conflicting guidelines.

Furthermore, this extra layer of licensing applies only to healthcare providers working with auto insurance claims; it is not required for services delivered under the Ontario Health Insurance Plan (OHIP) or the Workplace Safety and Insurance Board (WSIB). Ontario is the only place in the world that imposes this kind of additional regulation on healthcare professionals, leading to burnout and frustration. Some professionals have opted to cease treating auto insurance patients altogether or have left Ontario.

 

HSP Licensing Imposes Unnecessary Administrative and Financial Burdens

The financial and administrative costs of maintaining an HSP license are substantial. From 2014 to 2024, healthcare providers have paid approximately $34 million in direct licensing fees to FSRA. Beyond this, there are considerable indirect compliance costs, including the time and resources needed to meet FSRA’s regulatory demands.

The framework’s implementation was driven by the insurance industry and the former government. It costs more to administer than FSRA collects in fees, leaving taxpayers and consumers to unknowingly foot the bill.

For healthcare providers, the cost of complying with FSRA’s requirements—such as submitting Annual Information Returns (AIRs), navigating complex billing systems, and preparing for audits—costs each clinic an estimated $5,000 annually. This amounts to an industry-wide compliance cost of $20 million per year, and over the lifetime of the HSP licensing framework, this has created a financial burden of roughly $200 million on the healthcare sector.

These costs translate into reduced resources for patient care. Every hour spent on compliance is time taken away from providing care to patients. Audits alone have caused a significant loss of patient care hours, exacerbating Ontario’s healthcare challenges.

 

HSP Licensing Fails to Prevent Fraud or Improve Care Outcomes

Since its establishment, FSRA’s HSP licensing has failed to demonstrate any significant impact on fraud prevention or patient care outcomes. Out of 1,950 audits conducted by FSRA by March 2021, fewer than 1% resulted in administrative penalties, most of which were for minor paperwork errors rather than fraudulent activity. This raises serious questions about the system’s efficacy in addressing fraud, its original purpose.

The 2022 FSRA Market Conduct Report only reinforced the frustration felt by healthcare providers. FSRA’s focus on minor administrative oversights, such as missing electronic signatures or delayed registry updates, does little to improve care but adds to the regulatory burden on clinics. For example, issues such as delayed registry updates due to complex invoicing systems that sometimes take over seven months to process are unfairly categorized as non-compliance, further diminishing trust between healthcare providers and FSRA.

Despite FSRA auditors privately admitting that many of these infractions are merely bureaucratic in nature, the agency’s leadership continues to enforce these audits, undermining healthcare professionals’ trust in their role as regulators. Healthcare providers are managing life-or-death situations daily, and they should not be forced to divert their attention to minor administrative tasks that have no bearing on patient care.

 

HSP Licensing Negatively Affects Healthcare Providers and Patients

FSRA’s licensing framework actively limits patient access to rehabilitation services by forcing providers to opt out due to the burden of compliance. Many healthcare professionals choose not to renew their licenses, leading to a reduction in licensed providers available to treat motor vehicle accident victims. This lack of available care providers leads to prolonged recovery times and increases the likelihood of long-term disability.

 

The Economic Advantages of Removing HSP Licensing

In terms of economic impact, reducing unnecessary regulations like the HSP licensing framework can boost Ontario’s overall productivity. Streamlining regulation allows healthcare providers to redirect their time and resources toward innovation, patient care, and economic growth, rather than compliance. Simplifying Ontario’s regulatory landscape will encourage a healthier flow of resources, leading to economic benefits that extend beyond the healthcare sector.

 

Healthcare Providers and Their Colleges Are Already Effective Fraud Deterrents

Healthcare professionals, guided by ethical standards and oversight from their respective colleges, serve as the primary line of defense against fraudulent behaviour. The regulatory framework provided by these colleges already ensures that fraudulent activities are minimized. Given the low fraud discovery rate under FSRA’s HSP licensing—fewer than 1% of audits result in significant penalties—it is clear that professional colleges are already effective in this regard.

 

A “Closed Garden” Ownership Model for Better Billing Practices

A more effective approach to preventing billing issues is to look at the ownership structure of clinics. A “closed garden” model, similar to the one used in Ontario’s pharmacy sector, where ownership is restricted to licensed professionals, could help maintain the integrity of billing practices in healthcare. Under this model, at least 50% of rehabilitation clinic ownership should belong to regulated healthcare providers like physiotherapists or chiropractors.

 

Conclusion: Eliminate the HSP Licensing Framework

The FSRA’s HSP licensing framework is an unnecessary and costly addition to Ontario’s regulatory environment. It duplicates the oversight already provided by healthcare colleges, adds significant administrative and financial burdens to healthcare providers, and has shown little benefit in terms of fraud prevention or improved patient care outcomes.

By removing HSP licensing, Ontario can streamline its regulatory processes, reduce costs for healthcare providers and consumers, and improve the efficiency of its healthcare system. This change will allow providers to focus on delivering high-quality care, unencumbered by redundant regulations, while benefiting patients with faster, more responsive healthcare services.

In a time of great strain on Ontario’s healthcare system, eliminating unnecessary regulation such as HSP licensing is a critical step toward more efficient governance. The abolition of this framework will allow FSRA to redirect its resources to areas that genuinely need regulation, such as unregulated sectors like body shops and tow truck services, creating a more focused and impactful regulatory environment.

 

 

As of October 2024, compensation for healthcare providers treating motor vehicle accident victims in Ontario is below what it was in 1996. Health professionals have effectively been subsidizing the auto insurance sector, delivering care for complex cases at capped rates that set both the patient and provider up for failure. Interaction with the Financial Services Commission of Ontario (FSCO), the Financial Services Regulatory Authority (FSRA), and the insurance lobby has left professionals frustrated and disillusioned. Their concerns, ranging from inadequate fees and the burden of excessive red tape to redundant licensing requirements, have been repeatedly ignored. These ongoing challenges have created an untenable situation that has resulted in a system where administrative overhead, not care, has become the major cost driver for auto insurance premiums. Consequently, patients do not achieve optimal recoveries and are shifted onto the public health system, where they remain for the rest of their lives. This outcome is the product of ignoring healthcare professionals while giving undue weight to the misleading narratives of the insurance lobby.

This problem has persisted for over two decades because we’ve continued to listen to the same voices that have led us down the wrong path.

In 1996, healthcare providers received $120 per treatment session, which was reduced to $84 per hour in 1997. Today, the rate remains a mere $99.75 per hour. Moreover, the Minor Injury Guideline (MIG) further reduces compensation to an unsustainable $200 for a four-week treatment block. This manipulation by financial regulators, favouring the insurance industry, has harmed healthcare practices and resulted in moral injury, driving many professionals away from treating accident victims.

Healthcare providers across Ontario play a critical role in the recovery of those severely injured in motor vehicle accidents. Unfortunately, the FSRA’s current Professional Services Guidelines (PSG) and MIG fail to provide adequate compensation for the services necessary for complete rehabilitation. Despite Ontario being the most expensive province for auto insurance, FSCO never reviewed the MIG after the promised five-year trial period, nor did they index it for inflation. This has left Ontario with the lowest MIG compensation in the country.

The failure to update these guidelines has led to poor patient outcomes, over-reliance on the public health and welfare systems, and the financial destabilization of healthcare practices. Many patients who lose their jobs following a car accident become reliant on ODSP, turning once-productive citizens and taxpayers into dependents of the social safety net.

This document outlines the pressing need for substantial increases in PSG rates, a revision of the MIG cap, and an examination of the broader effects that the FSRA’s policies have on patient care, the healthcare system, and societal costs.

 

Insufficient Compensation Yields Poor Recovery Outcomes

– Current Payment Structure: Under the Statutory Accident Benefits Schedule (SABS), physiotherapy services are reimbursed at approximately $99.75 per hour. This rate is insufficient to cover the costs of delivering quality care, including the necessary administrative work, equipment, and overhead. In contrast, tradespeople like electricians and plumbers earn around $195 per hour—nearly double what physiotherapists receive for equally skilled labour.

– Impact on Care Quality: The low reimbursement rates force healthcare providers to see more patients simultaneously, leading to less time spent with each patient. This compromises the care provided and results in incomplete recoveries. Patients who don’t receive adequate rehabilitation are more likely to develop chronic conditions, placing a heavier burden on the healthcare system over time.

– Healthcare Provider Exodus: The low pay rates have driven many skilled providers out of Ontario to jurisdictions where their work is properly valued. This further reduces the availability of qualified professionals and negatively impacts patient outcomes.

 

Market Manipulation in the Healthcare Sector

– The Consequences of Cost Suppression: FSRA’s policy of artificially capping PSG rates has led to worse patient outcomes and higher costs for the healthcare system overall. By underpaying healthcare providers, the regulator has driven professionals away, which has decreased the quality of patient care.

– Poor Patient Outcomes: The compensation structure under both the PSG and MIG does not provide for sufficient care, resulting in inadequate recoveries for many patients. The $3,500 MIG cap, in particular, is insufficient for treating injuries that require extensive rehabilitation.

– Neglecting to Track Outcomes: The FSRA has not adequately tracked recovery outcomes or return-to-work rates. The focus on controlling costs rather than ensuring patient well-being has led to poorer recovery rates and greater societal costs.

 

The Flawed Logic Behind Fearing Higher Premiums

– The Cost of Complete Recovery: The argument that raising PSG rates would increase insurance premiums is overly simplistic. Facilitating complete recoveries through appropriate compensation for care is far more cost-effective in the long run, as it reduces reliance on the public health system and cuts down on settlement and administrative expenses.

– The True Cost of Inadequate Care: Incomplete recoveries result in much higher long-term costs, including those associated with chronic pain, disability benefits, and decreased workforce participation. The current system, which emphasizes short-term savings, ultimately burdens both the public health system and taxpayers.

– Fair Compensation for All: If the FSRA is determined to keep fees suppressed due to concerns over premium hikes, it should apply the same logic to executive compensation within insurance companies. Reducing their pay to 1996 levels would mirror the cuts forced on healthcare providers nearly three decades ago.

 

The Impact of Mandatory Auto Insurance

– Captive Consumers, Inefficient Service: Mandatory auto insurance in Ontario means that consumers must purchase coverage regardless of the quality of care they receive. This results in a system with little incentive for insurance companies to improve efficiency or ensure proper care for accident victims.

– Corporate Gains Over Patient Welfare: By keeping compensation for healthcare providers low, insurance companies can boost their profits at the expense of patient care and public welfare.

– Shifting Costs to the Public: When private insurers avoid paying for adequate care, the costs are passed onto the public system. This results in higher expenses for society as patients who don’t recover fully end up dependent on public welfare systems.

 

The Complexity of Motor Vehicle Accident Injuries

– Complicated, Multi-System Injuries: Injuries from car accidents often affect multiple parts of the body, such as the neck and shoulders, requiring a holistic approach to treatment. A lack of sufficient care exacerbates these issues, leading to longer recovery times and more chronic conditions.

– Severity of High-Velocity Trauma: Car accident injuries tend to be more severe than everyday injuries and require comprehensive rehabilitation to address both physical and psychological trauma.

 

The Disparity Between Healthcare and Trade Compensation

– Higher Pay for Trades: It is concerning that insurance adjusters value tradespeople like plumbers at nearly double the rate of healthcare providers. This discrepancy devalues the critical work of healthcare professionals and compromises the care patients receive.

– The True Cost of Underpaying Providers: By underpaying healthcare providers, the system fails patients, resulting in poorer recovery outcomes and higher long-term costs for society.

 

Conclusion and Recommendations

– Raise PSG Rates: Compensation should be increased to $400 for 50 minutes of care, reflecting the complexity and intensity of the rehabilitation services required for full patient recovery. This adjustment will reduce the outflow of skilled providers from Ontario and improve patient outcomes.

– Revise and Index the MIG Cap: The MIG cap should be raised to $15,000 and adjusted for inflation. This will provide adequate funding for necessary treatments, reduce reliance on public healthcare systems, and support more complete recoveries.

– Improve FSRA Accountability: The FSRA must focus on tracking recovery rates and return-to-work outcomes, prioritizing patient well-being over cost containment.

– Align Insurance Practices with Public Health Goals: Insurance company practices must support broader public health objectives, ensuring that healthcare providers receive adequate compensation to cover the cost of comprehensive care.

By adopting these reforms, Ontario can improve outcomes for accident victims, support its healthcare professionals, and build a more equitable and efficient healthcare system.

 

 

Introduction:

Imagine trying to use an outdated smartphone—its screen cracked, apps running slowly, and software so outdated that even the simplest tasks feel cumbersome. The frustration you experience when it fails to meet modern demands mirrors what healthcare professionals face every day using the outdated Health Claims for Auto Insurance (HCAI) system. While technology in other areas progresses, HCAI remains stuck in a time warp, with its inefficiencies continuing to frustrate providers. Unlike newer, more intuitive systems available today, HCAI’s dated platform drags down healthcare professionals’ ability to deliver timely care. This stark gap in efficiency highlights the pressing need for modernization.

In stark contrast, insurers’ requests for improvements to HCAI are quickly addressed. As reported by Canadian Underwriter in 2012, when insurers raised concerns about difficulties reconciling health invoices, the Financial Services Commission of Ontario (FSCO) responded swiftly, making changes to the system to meet their needs. This disparity reveals a troubling pattern: while insurers seem to have a fast-track for changes, healthcare providers are left struggling with an outdated system that doesn’t support their needs. For example, insurers’ requests for mandatory fields are quickly implemented, yet healthcare providers’ appeals, such as adding a signature line for invoices, go unaddressed.

The HCAI System: An Administrative Bottleneck Hindering Healthcare Delivery

As someone deeply concerned with improving healthcare system efficiency, I view the current version of the Health Claims for Auto Insurance (HCAI) system as deeply flawed. HCAI, which was designed to simplify the management of auto insurance health claims, has instead become an administrative burden for providers. The system’s complexities create unnecessary red tape, diverting healthcare professionals’ attention from their core mission—caring for patients. Not only does it increase the likelihood of human error, but it also delays payments and creates further administrative work to correct avoidable mistakes. These errors are often classified as compliance issues, further frustrating healthcare professionals who are already struggling with delayed payments.

Meanwhile, other organizations like the Workplace Safety and Insurance Board (WSIB) have adopted more efficient platforms such as TELUS Health’s eClaims, demonstrating that HCAI’s antiquated system is unnecessary. The contrast between these two systems illustrates the need for urgent reform in Ontario.

HCAI’s inefficiencies impede patient care by limiting the information that can be transmitted. Unlike the TELUS eClaims portal, which allows providers to attach memos that include critical patient information, HCAI’s rigid system often strips away important details. The reliance on coding in HCAI means that when a healthcare provider submits an invoice using a diagnostic code, the insurance adjuster only sees the code, not the detailed descriptions clinicians include. This disconnect between clinicians and adjusters prevents accurate assessments of treatment plans and creates a distorted view of patient needs, undermining the system’s value.

Even though HCAI was created to handle health claims, it doesn’t allow for attachments and lacks other basic functionalities that would streamline communication. In many ways, the system seems frozen in time, much like the Minor Injury Guideline (MIG) system that hasn’t seen the promised review for 15 years. Healthcare providers are left waiting for improvements that never materialize.

The Impact of Inefficiencies on Healthcare Providers

Healthcare providers dedicate their time and energy to delivering quality care. Yet, when systems like HCAI are riddled with inefficiencies, their ability to focus on patient care is severely compromised. The HCAI system is an example of this, with its convoluted forms, lack of user-friendly features, and inadequate communication tools.

Since its launch in the early 2000s, the HCAI system has seen little to no improvement, even as other sectors and healthcare platforms have evolved. This stagnation is particularly concerning when compared to more modern systems, such as TELUS Health eClaims, which offer a more streamlined, user-friendly experience.

Complex, Redundant Forms: A Barrier to Efficiency

One of the major challenges with HCAI is the complexity and redundancy of its forms, particularly the OCF-18 (Treatment and Assessment Plan) and OCF-21 (Invoice). These forms require repetitive entry of information across multiple sections, creating unnecessary duplication and increasing the risk of errors. Healthcare providers spend valuable time filling out these forms, time that could be better spent on patient care.

The complexity of the forms is reflected in the extensive user manuals required to navigate them. For busy healthcare professionals, this is impractical and further detracts from patient care. Even minor submission errors can delay payments, creating additional stress for providers trying to manage their practices effectively.

Inadequate Communication and Feedback Loops

A significant shortcoming of the HCAI system is its failure to facilitate effective communication between healthcare providers and insurers. Often, insurers provide vague or generic responses to submitted claims, offering little guidance on why a claim was denied or modified. This lack of clarity forces providers to engage in a frustrating cycle of resubmitting forms without understanding what changes need to be made.

Despite being designed specifically for the healthcare sector, HCAI lacks basic functionalities like messaging systems or the ability to attach supporting documents. These limitations increase delays and administrative burdens for providers, who must resort to faxing or emailing crucial documentation separately, further complicating the process.

Prioritizing Insurers Over Healthcare Providers

One of the most frustrating aspects of HCAI is the system’s rigidity when it comes to mandatory fields. While FSCO and FSRA have been quick to address insurers’ requests for new fields to assist in reconciling invoices, they have consistently ignored healthcare providers’ requests for critical changes, such as adding a signature line for invoices.

This imbalance between the needs of insurers and healthcare providers highlights a systemic issue in the management of the HCAI platform. While insurers’ requests are prioritized, healthcare providers are left dealing with operational red tape and delays that ultimately impact patient care.

A Long-Standing Problem with Invoicing Cycles

The frustration healthcare professionals experience with HCAI is not new. For years, they have requested changes to the invoicing cycle, asking regulators to allow monthly submissions instead of requiring invoices every 31 days. This discrepancy created significant operational difficulties for clinics, which struggled to adjust their invoicing cycles each month. After years of advocacy, FSCO finally amended the rule in 2014, allowing for more consistent monthly submissions. However, this change only came after significant strain on providers.

Unfortunately, FSRA has inherited this same tendency to overlook healthcare providers’ concerns. Despite replacing FSCO, the issues faced by clinics and the patients they serve have not been adequately addressed.

HCAI’s Failure to Accept Attachments: A Major Oversight

In the digital age, the inability of HCAI to accept attachments is a glaring flaw. Supporting documents like diagnostic reports and specialist evaluations are essential for substantiating treatment plans. Yet, HCAI forces healthcare providers to send these documents separately, fragmenting the process and increasing the likelihood of miscommunication and lost paperwork.

This oversight is particularly concerning for a platform specifically designed to handle healthcare claims. Without the ability to centralize all relevant information, the system’s inefficiencies are compounded, making an already cumbersome process even more difficult.

TELUS Health eClaims: A Better Alternative

In contrast to HCAI, TELUS Health’s eClaims portal offers a more efficient, user-friendly system for processing claims. It allows healthcare providers to submit detailed memos and attach critical documentation, keeping everything within a single platform. This system greatly reduces the risk of miscommunication and ensures that important details aren’t lost in translation.

The comparison between TELUS Health’s platform and HCAI highlights the potential for improvement. A more streamlined, efficient system is not only possible but already in use within the industry.

A Call for Reform and FSRA’s Role

In light of these challenges, FSRA must take immediate action to overhaul the HCAI system. Recent announcements from FSRA about reviewing various guidelines and systems, including HCAI, provide an opportunity to push for meaningful change.

However, FSRA must also prioritize its resources effectively. Redirecting focus to unregulated areas like tow truck operators and auto body shops—both of which are central to the auto insurance process but currently operate without oversight—would help ensure a more comprehensive approach to regulation.

Recommendations for a Modernized HCAI System

To transform HCAI into a platform that supports healthcare providers and patients, several key changes are necessary:

1. Streamline Forms and Processes: Eliminate redundancy and simplify the forms to reduce administrative burden. Features like autofill and real-time error checking would help minimize mistakes and expedite submissions.
2. Enhance Communication Features: Integrate a messaging system within HCAI to facilitate direct communication between providers and insurers, reducing delays caused by unclear feedback.
3. Allow Document Attachments: Enable providers to attach supporting documents like diagnostic reports directly within the system, centralizing information and streamlining the claims process.
4. Introduce Real-Time Issue Resolution: Adopt real-time feedback systems similar to those used by TELUS Health, allowing providers to quickly resolve issues.
5. Provide Clear Adjudication Feedback: Offer detailed explanations for claim decisions to help providers understand what changes are needed without unnecessary back-and-forth.
6. Automate Recurring Claims: Enable automation for recurring claims to reduce the time spent on ongoing treatment submissions.

Conclusion: Time for Change

The HCAI system is outdated and inefficient, placing unnecessary administrative burdens on healthcare providers and delaying patient care. While insurers’ requests for system improvements are swiftly addressed, healthcare professionals continue to struggle with rigid forms, a lack of communication tools, and an inability to attach essential documents. To ensure fair and efficient claims processing, FSRA must modernize HCAI by streamlining forms, enabling document attachments, improving real-time feedback, and enhancing communication between providers and insurers. These changes are essential to reducing delays, improving patient outcomes, and ensuring that accident victims receive the care they need without unnecessary obstacles.

For seriously injured Ontarians, attendant care is not a luxury—it is a necessity. It is the most basic level of care that allows individuals with brain injuries, spinal cord injuries, amputations, and other serious conditions to live with dignity. Yet, despite paying into mandatory auto insurance, accident victims are being denied the benefits they need due to outdated regulations, insurance industry loopholes, and unfair payment practices.

The recent Malitskiy v. Unica decision has worsened this crisis, allowing insurers to manipulate attendant care payments, shortchange claimants, and effectively undermine the entire system. If this trend continues, the burden will shift to families, the public healthcare system, and ultimately, taxpayers.

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How Did We Get Here? The Decline of Attendant Care Benefits

Over the years, Ontario’s Statutory Accident Benefits (SABs) have been steadily eroded. It has become harder for injured individuals to access the benefits they are entitled to, despite being innocent, premium-paying accident victims.

Key issues include:
✔ Outdated Form 1 Rates – The hourly rates used to calculate attendant care benefits have not been updated in decades. The result? Many Personal Support Workers (PSWs) are being paid less than minimum wage for their services.
✔ Insurers Underpaying Benefits – Instead of paying the full amount approved on the Form 1 assessment, insurers pay only partial amounts, forcing claimants to cover the shortfall.
✔ Restricted Access to Form 1 Assessments – Only Occupational Therapists (OTs) and nurses can complete Form 1 assessments, despite physiotherapists and chiropractors being equally qualified to determine attendant care needs.

The consequence? More accident victims are left without care, relying on overburdened family members or OHIP-funded services that were never designed to fill this gap.

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The Malitskiy v. Unica Decision: A Dangerous Precedent

The Malitskiy v. Unica case has set a damaging precedent in the auto insurance industry. Following the decision, insurers such as Economical, Sonnet, and Definity have refused to pay fair rates for attendant care, citing the outdated hourly rates set in the Form 1.

This means:
🚨 Attendant care providers are being forced to work for unsustainable wages.
🚨 Claimants must pay out-of-pocket to make up the difference.
🚨 Families are being left to care for seriously injured loved ones, often quitting their jobs to do so.

If this loophole is not addressed, more insurers will follow suit, leading to a total breakdown of access to care.

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The True Cost of Attendant Care: Why the System Is Unsustainable

The insurance industry’s refusal to update rates ignores the real-world costs of providing attendant care. Since the COVID-19 pandemic, the cost of hiring and retaining PSWs has risen significantly.

Here’s why:
✔ Higher Wages – The Ontario government increased PSW wages in the public sector by $3 per hour, forcing private employers to follow suit.
✔ Rising Business Costs – Employers must cover CPP, EI, WSIB, liability insurance, recruitment, training, and administrative costs.
✔ Health Care Inflation – The cost of healthcare services rises 1.5 to 2 times faster than general inflation—yet Form 1 rates remain stuck in the past.

For example, a PSW earning $25 per hour actually costs an employer $27.48 per hour when employment costs are factored in. Add business overhead, and the actual cost of providing care is between $55-$60 per hour—yet insurers refuse to recognize this.

If this issue is not addressed, the pool of available PSWs will shrink, leaving seriously injured individuals without professional care.

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Solutions: Fixing Ontario’s Attendant Care System

✅ 1. Update Form 1 Rates
The Form 1 rates should reflect current wages, employment costs, and the true cost of providing care. Rates should be adjusted regularly to align with public health facility rates and inflation.

✅ 2. Pay Based on Approved Time, Not Arbitrary Hourly Caps
The Form 1 was intended to provide a monthly benefit, not to enforce below-market hourly rates. Insurers must be required to pay for the full approved time, at competitive market rates, as originally intended.

✅ 3. Expand the Pool of Professionals Who Can Complete Form 1
Occupational Therapists and nurses are not the only qualified professionals to assess attendant care needs. Physiotherapists and chiropractors—who are often the first-line healthcare providers for injured individuals—must be allowed to complete Form 1 assessments. This will increase accessibility and reduce costs for patients.

✅ 4. Increase Cap Rates for Attendant Care
The current $3,000/month (non-catastrophic) and $6,000/month (catastrophic) caps are outdated and unrealistic. These limits must be increased to ensure that individuals receive the level of care they need.

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Why This Matters for Ontarians

This issue doesn’t just affect those injured in car accidents—it affects everyone in Ontario.

🔹 Families are being forced to care for loved ones without proper support.
🔹 The public healthcare system is absorbing costs that insurers should be covering.
🔹 PSWs and care providers are leaving the field due to unsustainable wages.
🔹 Insurers are profiting while victims are left without the care they paid for.

Ontarians pay for auto insurance expecting to be covered if the worst happens. Yet, insurers are denying care, shifting costs to families, and exploiting outdated policies. This must change.

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Conclusion: Time for Action

The Malitskiy v. Unica decision has exposed a major flaw in Ontario’s auto insurance system—one that will harm victims, burden families, and strain public healthcare resources if left unchecked.

To protect seriously injured Ontarians, we must:
✔ Update Form 1 rates to reflect real costs
✔ Ensure full payment for approved services
✔ Allow more healthcare professionals to assess needs
✔ Increase cap rates to ensure adequate care

If action isn’t taken now, access to attendant care will continue to decline, and Ontario’s most vulnerable will pay the price.

💡 It’s time to hold insurers accountable and demand fair access to care for all Ontarians.

#InjuryAdvocacy #FairAccessToCare #AutoInsuranceReform #AttendantCareRights

The Injury Advocates represent health care providers and legal professionals supporting seriously injured people across Ontario. Working in the Motor Vehicle Accident sector, we have witnessed a steady depletion of available benefits over the years. It has become increasingly difficult for consumers to access the crucial benefits they rely on for their safety and recovery. That has left severely injured innocent premium paying accident victims with no alternative but to access OHIP funded services, family members, and often without help at all. The barriers to access for treatment and care have increased the burden on the public purse, caused economic harm to family members who have had to leave jobs to support their seriously injured family members and left many without care and treatment. Recently, we have seen a concerning trend of denied support stemming from the Malitskiy v. Unica decision.

Attendant care is the most basic level of care for individuals with serious injuries such as brain injuries, spinal cord injuries, serious orthopedic injuries, and/or amputations. It enables a Personal Support Worker to assist with essential tasks like personal care, safety, supervision, meal preparation, hygiene, and other therapies.

The Form 1 assessment was originally designed to calculate the monetary amount injured individuals could use to hire a Personal Support Worker. Here is a quote from the Financial Services Commission of Ontario (FSCO) 2018 bulletin:

1. Attendant Care Hourly Rate Guideline

Calculation of Monthly Benefit

The Attendant Care Hourly Rate Guideline has been revised to require that the maximum hourly rates set out in the guideline be used with the Assessment of Attendant Care Needs (Form 1) to calculate the monthly attendant care benefit in accordance with section 19 (2) of the Statutory Accident Benefits Schedule – Effective September 1, 2010 (SABS).

Previous guidelines could be interpreted to strictly apply the maximum hourly rates as the maximum payable for attendant care services, rather than using the hourly rates to calculate a monthly benefit as was originally intended.

The approved amount on the Form 1 is calculated by multiplying the time required each month for a specific type of support by the Form 1 hourly rate assigned to that service (e.g., $14.00, $14.90, and $21.11).

Concerns Regarding Economical Insurance’s Post-Malitskiy v. Unica Attendant Care Policies

In the aftermath of the Malitskiy v. Unica decision, Economical Insurance, along with its related companies Sonnet and Definity, has implemented sweeping policies that severely limit payments for attendant care based on outdated hourly rates. These rates are now not only below minimum wage but also fail to account for essential business-related expenses.

As a result, insurers are making only partial payments on invoices, leaving claimants responsible for covering the shortfalls. This practice effectively shifts the financial burden onto critically injured individuals and their families, jeopardizing their access to necessary care.

By exploiting this legal loophole, these companies are setting a dangerous precedent. If left unaddressed, other insurers may follow suit, further eroding the standard of care for vulnerable claimants, all while sidestepping regulatory or legal accountability.

This issue urgently needs attention, as the continued undermining of the system will have long-lasting repercussions on the quality of care and financial fairness for injured individuals.

Costs related to Providing Attendant Care services

There are many costs associated with providing Attendant Care services, most of which have drastically increased with the Covid-19 Pandemic.

As many Ontarians know, the province is experiencing a shortage of Personal Support Workers and Care Providers. This shortage has led to increased competition among employers and agencies to attract and retain workers. To stay competitive, companies have been forced to significantly raise wages.

Additionally, the Ontario government promised a $3 per hour wage increase for Personal Support Workers in the public sector. In response, private sector employers had to match or exceed this pay increase to remain competitive, resulting in further wage adjustments. These rates have not decreased since and are expected to continue rising over time. Employment costs for a Personal Support Worker include contributions to the Canada Pension Plan (CPP),

Employment Insurance (EI), Ontario Health Taxes, and Workplace Safety and Insurance Board (WSIB). If a PSW is paid $25 per hour, the employer’s contributions would be as follows:

• Employer CPP Contribution: $1.49

• Employer EI Contribution: $0.57

• WSIB Contribution: $0.42

Thus, the total cost per hour for this Personal Support Worker would be $27.48.

Other costs associated with running attendant care businesses include:

• Insurance Costs: Premiums for liability, property, and third party auto insurance.

• Recruiting Costs: Expenses related to attracting and hiring qualified staff.

• Administrative Costs: Overhead expenses for office management and other administrative functions.

• Losses: Financial losses due to factors such as staff turnover or unpaid services.

• Other Costs: Miscellaneous expenses that may arise, including training, equipment, and supplies.

In addition to these costs, health care expenses are known by economists to increase at a rate 1.5 – 2 times the inflation rate. Factors such as inflation, the potential for future pandemics, and other unforeseen events can significantly impact the cost of services. It is essential to consider these factors when planning for the future costs of attendant care services. Without adjusting the hourly rates now to be in line with commercial costs, premium paying accident victims are deprived support from a diminishing pool of PSW’s willing to work for less than they can receive working for other employers, including the Ministry of Health, which pays hourly rates and benefits above commercial rates.

Without adjusting the rates, with PSW’s unable and unwilling to work for below minimum wage/commercial rates, the burden of care poses a large economic cost on the province and families, both of whom are thrust into the position of having to provide care when insurers breach the insurance contract they have with voters/premium payers and deny or fail to pay the full monthly rate calculated, to pay qualified PSW’s.

Solutions:

A: Increasing Accessibility to Assessment of Needs to other qualified health care practitioners: Currently, only nurses and OT’s are allowed to complete the Form 1. There is no basis for this restriction, which limits access to care for those with severe injuries who can not access the treatment of many practitioners without psw support. Often the gateway to recovery begins with physiotherapy and chiropracty. The decision to remove the ability of certain healthcare professionals, such as physiotherapists and chiropractors, to complete the Form 1 was a significant misstep by the previous government. The completion of Form 1 is well within the scope of practice for these professionals, particularly for physiotherapists, who are uniquely qualified to diagnose and convey a diagnosis. By restricting the completion of Form 1 solely to Occupational Therapists and nurses, patient access to this essential service was unjustly limited. This change not only made it more costly for patients to obtain a Form 1 but also reduced their ability to even access it when needed. The Financial Services Commission of Ontario (FSCO) made this decision in response to insurance industry lobbying without adequately consulting healthcare colleges, professionals, or patient advocacy groups. This restriction on healthcare professionals’ scope of practice offloads costs onto the public healthcare system, reduces access to care, and ultimately harms patient outcomes. This mistake needs to be rectified to restore patient access to necessary services.

Solutions to the issues stemming from the Malitskiy v. Unica decision should focus on allowing companies to bill competitive rates and ensuring full payments for approved services. We propose the following options:

1. Updating Form 1 Rates: Adjusting the Form 1 rates to reflect current public health facility rates nor market rates that attendant care companies need to charge to provide services, nor is there a mechanism allowing access to cost increases caused by inflation and limited resources.

2. Billing Based on Approved Time: The Form 1 unilaterally divides into 3 categories for care. Many of the services overlap. It is meant to be holistic. It is painfully ironic and tragic when insurers defeat the holistic intention by indicating they will only pay x minutes for level one care at its 1990’s rate, y minutes for level 2 care at its 1990’s rate and z minutes for level 3 care at a 1980’s rate. Calculating the total minutes that the claimant is approved for and allowing companies to bill their own rates for the time spent providing care is what was intended and what was directed by the Superintendent, but not being followed by insurers. This is the preferred method, as it more readily accommodates market adjustments and encourages companies to offer competitive pricing to attract clients. Claimants can then seek out competitive rates and choose which company they wish to provide the service.

This is similar to the WSIB model whereby agency attendant rates are negotiated with and paid directly to the agency.

Long term care homes, private nursing homes and the Ministry of Health contracts with agencies to provide services and pays them on the hours used model. The prepaid contract for accident benefit funded care on an if and when needed basis puts billions of dollars into the hands of insurers for contingent needs, providing a windfall unless there is an accident. When an accident happens and the severely injured innocent premium paying accident victim voter has a need and the insurer wont follow the government regulations and pay for that need, we all suffer.

3. Expand the Pool of Professionals Authorized to Complete Form 1: To ensure broader access to filling out Form 1s without increasing costs for this service, it is appropriate to recognize the acumen of other health care professionals and practitioners to complete the Form 1, especially when those same practitioners are the first line of support for seriously injured accident victims. We propose expanding the pool of healthcare professionals authorized to complete Form 1. Specifically, physiotherapists and chiropractors should be reauthorized to complete this form, as it falls well within their scope of practice. These professionals are uniquely qualified to assess and diagnose conditions that necessitate attendant care, making them well-suited to determine the level of support a patient requires. By expanding the pool of authorized professionals, we can reduce barriers to accessing Form 1, lower costs for patients, and improve overall patient outcomes by ensuring timely and appropriate care. This change would rectify the oversight that occurred when the ability to complete Form 1 was unjustly restricted, ultimately enhancing patient care and access

4. Increase Cap Rates: Cap rates have also remained unchanged for many years, which poses challenges for seriously injured clients who require significant care. Currently, the maximum amount of approved funds is $3,000 per month for non-catastrophically injured clients and $6,000 per month for those who are catastrophically injured. These limits need to be increased to accurately reflect the true cost of providing necessary care.

Implementing these changes will help ensure that Ontarians seriously injured in motor vehicle accidents receive the necessary care funded by the mandatory auto insurance benefits they have paid for.

Proposed Rate

A proposed rate of $55-$60 per hour for attendant care services is justified by the need to cover the full spectrum of costs associated with providing high-quality care while ensuring the sustainability and competitiveness of the business.

Key Factors Justifying the Rate:

1. Wages and Employment Costs: Personal Support Workers (PSWs) in Ontario are often paid around $25 per hour. When you include mandatory employer contributions such as CPP, EI, and WSIB, the actual cost to the employer rises to approximately $33 per hour. This amount in no way accounts for the cost of ensuring services are provided, detailed below, under Business Overhead.

2. Business Overhead: Running an attendant care business involves significant overhead costs, including insurance premiums, recruiting expenses, administrative operations, and ongoing training. These overhead costs can add another 35-40% on top of direct labour costs, bringing the total hourly expense to around $45 per hour.

3. Profit Margin for Sustainability of Small Businesses, the engines of Ontario’s economy: For a business to remain viable, it must also include a reasonable profit margin. In service industries such as healthcare, a profit margin of 20-25% is necessary to ensure the business can reinvest in quality improvement, absorb unforeseen costs, and remain competitive in attracting top talent. This brings the hourly rate to approximately $55-$60.

Competitive Market Rates:

In the Canadian context, where service rates are higher due to high housing costs, high transportation costs and increased costs of living and doing business, a rate of $55-$60 per hour aligns with what other skilled services charge. For example, plumbing and electrical services in Canada typically range from $100 to $150 per hour, reflecting similar cost structures and the need to sustain business operations.

Conclusion:

A rate of $55-$60 per hour is not just a reflection of current market conditions but a necessary adjustment to ensure that businesses providing attendant care services can cover all operational costs, offer competitive wages, and maintain a sustainable profit margin. This rate will allow accident victims and voters confidence that the services they need will be able to be made available when they need it most, and ensure the quality of care remains as high as it is in the public sector, and commercial sector, with the same qualification of skilled personal support workers available and willing to work in public, private and insurer funded sectors for an equal and fair wage.

The Malitskiy v. Unica decision requires urgent attention, particularly regarding the calculation of attendant care payments. It is essential to clarify that the hourly rates in Form 1 Assessments are intended only as a means to calculate a monthly monetary amount, not as a cap on the hourly rate for agency services. These rates should not be misconstrued as maximum allowable rates, as they do not reflect the current market conditions or the true costs of providing care.

With the support of these important legislative and regulatory adjustments, Ontario voters and its economy will get what they have paid for from their insurers and will not be forced to pay doubly for the same service, once through their auto insurance premiums and second through unnecessary use of tax health care dollars which should only be used to provide services for those who don’t have the benefit of paid for insurance health care services.