Medical and Rehabilitation Benefits

In order to facilitate maximum recovery following an accident, it is highly important that an injured person access a team of medical and rehabilitation providers who are experts in their respective fields. Payment for such vital services, as well as for any recommended goods required from a medical or rehabilitation perspective, can be accessed through the injured person’s accident benefit claim.

The medical benefit will pay for reasonable and necessary goods and services including:

• Medical, surgical, dental, optometric, hospital, nursing, ambulance, audiometric and speech-language pathology services;
• Chiropractic, psychological, occupational therapy and physiotherapy services;
• Medication;
• Prescription eyewear;
• Dentures and other dental devices;
• Hearing aids, wheelchairs or other mobility devices, prostheses, orthotics and other assistive devices;
• Transportation for the injured person to and from treatment sessions, including transportation for an aide or attendant; and
• Other goods and services of a medical nature that the insurer agrees are essential for the treatment of the insured person, and for which a benefit is not otherwise provided in the Regulation.

The rehabilitation benefit will pay for reasonable and necessary expenses that are incurred for the purpose of reducing or eliminating the effects of a disability or to facilitate the person’s reintegration into family, society, or the labour market. Measures which may be considered in relation to the rehabilitation benefit can include:

• Life skills training;
• Family counselling;
• Social rehabilitation counselling;
• Financial counselling;
• Employment counselling;
• Vocational assessments;
• Vocational or academic training;
• Workplace modifications and workplace devices, including communications aids, to accommodate the needs of the insured person;
• Home modifications and home devices;
• Vehicle modifications; and
• Transportation for the insured person to and from counselling and training sessions, including transportation for an aide or attendant

Other goods and services that the insurer agrees are essential for the rehabilitation of the insured person.

As previously indicated, the combined medical and rehabilitation benefit coverage limit for a minor injury claim is $3,500. As also noted, the combined medical, rehabilitation, and attendant care benefit coverage limit is $65,000 and $1,000,000 respectively for non-catastrophic and catastrophic claims. These limits may be increased if optional benefits were purchased and in effect on the automobile policy at the time of the motor vehicle accident. Given this, a review of the policy coverage should be undertaken in the very early stages of the claim.

If a client has suffered a catastrophic impairment, they are entitled to hire a case manager to assist in coordinating care.

Additionally, in non-catastrophic cases, our accident benefits specialists are well positioned to support and encourage communication and coordination of care within the group of the injured person and family, and the rest of the medical and rehabilitation team while also liaising directly with the insurance company to facilitate the claim.

Yes, subject to the coverage amounts indicated above, there are also some limits on the time period during which medical and rehabilitation benefits may be accessed.

If a person is catastrophically impaired, medical and rehabilitation benefits will remain available to the injured person over the course of their lifetime. However, if an injured person is not catastrophically impaired, including when a minor injury has been suffered, the time limit for accessing medical and rehabilitation benefits is only five years. The exception to this non-catastrophic time limit is for those who were under the age of 18 at the time of the accident. In such cases, the person may have access to medical and rehabilitation benefits up until their 28th birthday.

The first step to accessing a medical or rehabilitation benefit is to submit an application for the benefit to the insurer. In nearly all cases, such an application is made by way of the submission of a Treatment and Assessment Plan. The application should be submitted before the medical or rehabilitation expense is incurred as the insurer will not otherwise be obligated to pay the expense.

There are some exceptions to the requirement that insurer approval be obtained prior to an expense being incurred. These exceptions include:

• Ambulance fees, or other expenses for services provided on an emergency basis within five days of the accident;
• Expenses that are reasonable and necessary as a result of an impairment for drugs prescribed by a regulated health professional; and
• Expenses that are reasonable and necessary as a result of an impairment for goods with a cost of $250 or less per item.

It is required that the Treatment and Assessment Plan be signed by a regulated health care professional as well as by the injured person, unless the insurer waives the requirement for a claimant’s signature. Additionally, the Treatment and Assessment Plan must include a statement by a health care practitioner approving the Treatment and Assessment Plan and stating that they are of the opinion that the goods, services, assessments and examinations described in the Treatment and Assessment Plan, and their proposed costs, are reasonable and necessary for the injured person’s treatment or rehabilitation, and the impairment sustained by the injured person is not predominantly a minor injury.

In considering the above requirements, it is important to consider who can prepare a Treatment and
Assessment Plan. For the purposes of the application for medical and rehabilitation benefits, “regulated health care professionals” include:

• Chiropractors
• Dentists
• Massage Therapists
• Nurses
• Occupational Therapists
• Optometrists
• Physicians
• Physiotherapists
• Psychologists
• Social Workers
• Speech-Language Pathologists

For the purposes of the application for medical and rehabilitation benefits, “health care practitioners” who can approve Treatment and Assessment Plans include:

• Physicians
• Chiropractors
• Dentists
• Occupational Therapists
• Optometrists
• Psychologists
• Physiotherapists
• Registered Nurses with an extended certificate of registration
• Speech-Language Pathologists

Our accident benefits specialists will assist your treatment team with any issues encountered in preparing a treatment plan.

The insurer must promptly determine whether or not it is going to pay for the benefit for which an application has been made; the insurer must respond within 10 business days of receiving the application.

In the event the insurer does not respond to the application within the required time period, there are repercussions. If the insurer denies the recommended goods and services after the expiry of the 10th business day, the insurer is required to pay for any goods and services provided under the application for the period starting the day after the date the response was due (i.e. day 11) and ending on the day the insurer gives notice of the denial.

Further, if the insurer fails to respond to the Treatment and Assessment Plan within the required 10 business day period, the insurer is also prohibited from taking the position that the insured person has an impairment to which the Minor Injury Guideline applies.

Otherwise, if an application for a medical and rehabilitation benefit is approved, the injured person may proceed to purchase goods and services and submit invoices to the insurer directly as costs are incurred. In the event that the injured person has collateral insurance, through an employer policy or otherwise, any such invoices for expenses must first be submitted to the collateral carrier; the automobile insurer is only obliged to pay the balance remaining following collateral payment for the approved goods and services.