Job Specification

Purpose :

- To conduct/lead the negotiation and settlement of accident benefit claims and third-party bodily injury claims made against the Motor Vehicle Accident Claims Fund (MVACF).
- To provide expert advice and support on the MVACF.

Key Responsibilities :

1. Claims Investigation, Negotiation and Resolution
- Reviews and analyzes claims to the MVACF in accordance with relevant legislation, the Statutory Accident Benefits Schedule, Rules of Civil Procedure, and related policies and procedures to determine eligibility of the applicant.
- Provides technical expertise in the priority investigation of new claims to ensure that MVACF accepts claims only in accordance with legislation.
- Communicates/advises insurance companies, adjusters, investigators and legal counsel of interpretation of rules and procedures and alternate recourse for accident benefits.
- Investigates, analyzes, negotiates and settles disputes between insurers in accordance with relevant legislation, and directs the activity of adjusters, lawyers and investigators representing MVACF in various legal proceedings related to the dispute process.
- Assigns claims and provides direction to third party adjusters and legal counsel responsible for defending and settling accident benefit and third-party liability claims in line with established quantum
- Develops case management strategies/plans and provides technical information to legal counsel; advises on the interpretation of relevant legislation.
- Reviews, researches, analyzes, adjudicates and resolves accident benefit and personal injury claims in line with legal precedents on damages and ensures technical integrity and compliance with applicable regulations and legislation.
- Negotiates and approves claims settlements up to approved limits by attending mediations, tribunals and other legal proceedings with defence counsel.
2. Claims Expertise/Advice
- Provides expertise and advice to the manager, claims and litigation support officers and senior management on a range of claims and program related matters including statutory entitlement to benefits and valuation of damages, reserving (i.e. estimating the future possible financial liability to Ontario for given claims), and coverage interpretation, and application of various legislation, including the Motor Vehicle Accident Claims Act (MVAC Act), impacting claims.
- Provides support to managers on the development and communication of tools, processes and systems to support claims management and administration including claims handling standards, protocols and procedures to ensure consistency of approach by third party adjusters, claims and litigation support officers and legal counsel.
- Participates in projects for the research, development and implementation of new/revised claims policies, procedures and standards including new system development.
3. File Audits/Analysis and Information
- Reviews third party adjuster's compliance with agreed claims handling protocols and procedures, effectiveness in dealing with claims against the program, accuracy in reserving, approval/denial of benefits, payment of benefits and timeliness of file closure.
- Participates in file audits to ensure high quality, timely, effective and efficient responses in support of the MVACF program.
- Reports audit findings to management along with recommendations for improvement of service.
4. Information and Advice
- Informs and shares information with claimants, stakeholders, legal/insurance communities and the public regarding the functions of the MVACF and the types of claims that may be pursued.
- Provides analytical reports, recommendations, briefing notes and advice to senior staff and management regarding settlement issues and the resolution of complex claims.

Knowledge / Skill :

- Principles, industry standards and best practices of insurance administration, claims investigation and adjusting practices, negotiation and Ontario civil law procedure and case law and mediation, tribunal and arbitration techniques on insurance to review, negotiate and resolve claims and provide expert advice.
- Relevant legislation (e.g. Motor Vehicle Accident Claims Act, Insurance Act), to respond to issues, interpret and apply legislation in the assessment, payment, transfer, negotiation and settlement of claims.
- Claims handling protocols and procedures to provide expertise in support of the claims management program and to advise in the development and communication of tools, processes and systems to support claims management and administration.
- Mathematical skills to calculate financial exposure and assess reserves, and to review/approve structured settlement annuities and reversionary guarantees.
- Auditing and risk management assessment practices to lead and report on file audits, understand liability issues and assess claims risk.
- Oral and written communication skills to negotiate settlements, conduct/participate in mediations, arbitrations and hearings, advise on claims management standards, protocols and procedures, prepare reports, correspondence and briefing notes, and respond to a range of queries.
- Computer applications to research and prepare materials and related program related software (claims management system).

Interpersonal / Influencing Skill :

- Negotiation, influencing and customer service skills to interact with third party adjusters, legal counsel and the public in the investigation and resolution of claims.
- Consultation and advisory skills to provide expert advice and assistance on statutory accident benefits claims entitlements, reserving and coverage interpretations and the impact of legislation on claims.

Analyzing / Problem Solving Skill :

- Investigate/research and assess accident benefit and liability claims and calculate and analyze the financial exposure.
- Review cases to ensure claims processes, protocols, standards and approaches applied by third party adjusters, claims and litigation support officers, investigators and legal counsel meet insurance industry standards and program and legislative requirements.
- Research existing case law and statutes and assess trends of recent court decisions and accurately evaluate the province's exposure, identifying changes in case law and adapting to evolving claims management strategies.
- Conduct compliance and effectiveness audits of claims handling by third party adjusters.

Decision Making / Responsibility :

- Developing claims resolution strategies, making decisions on legal strategies that impact the direction and settlement of a claim.
- Assessing reserves, risks, damages and liability and financial impact of claim.
- Assigning claim cases and enduring high quality, timely and effective responses and compliance with agreed claims handling protocols and procedures.
- Providing expertise, advice and interpretation on application of legislative requirements to ensure the effective resolution of claims. Has latitude to authorize settlements up to an approved limit and discretion to provide instruction to adjusters and legal counsel. Decisions are guided by legislation, MVACF program policies, case law, claim handling procedures, legal precedents and branch practices.

Contacts / Stakeholder :

- Third party adjusters on operational issues, providing information/advice on the claims process, instructions on claims investigations, monitoring claims handling and conducting file audits.
- Insurers to discuss priority and coverage issues/disputes; and negotiate resolutions to disputes.
- Internal/external retained legal counsel to liaise and discuss claims strategies and resolution options and review and approve legal accounts.
- Plaintiff counsel to discuss merits of client's case and negotiate settlements.
- Medical community, structure settlement companies, the general public and claimants to interpret/explain policies and procedures, respond to inquiries regarding claims and negotiate settlements.

Guidance / Supervision :

- Provides technical guidance/advice and mentoring and training to new claims staff including technical guidance on files and claims processes.
- Provides technical advice and guidance to senior management, legal counsel on insurance coverage, claims handling standards, protocols.

Demands / Pressures :

Work Demands :

- Frequent requirement to deal with unexpected work demands and within tight time pressures (e.g. urgent phone calls, requests for legal instructions with short time frames) and with limited control over pace of work.
- Occasionally required to work beyond normal work hours with some disruption to personal life when attending mediations/arbitrations.

Mental / Sensory :

- Frequent requirement to read without interruption and concentrate intently when reading complex legal pleadings and legal/medical and other investigative reports.
- Frequently required to give instructions to legal counsel and external adjusters to ensure complete understanding of claim file.

Conditions / Environment :

- Work is performed in a typical office environment.