||Bill 59 (Nov. 1, 1996 to Sept. 30, 2003)
||Bill 198 (Oct. 1, 2003 to present)
|Important Time Limits
||Notice to the accident benefits insurer within 30 days of the accident.
||Notice to the accident benefits insurer within 7 days of the accident. (Where notice received after 7 days, insurer may delay determining benefits entitlement for up to 45 days after notice received.)An application for accident benefits must be submitted within 30 days of receipt of application forms from the insurance company. Many other time limits from SABS that is applicable to our Health Care Professionals i.e. re: Assessment Plan, Tx Plan, DAC.
|Examinations under Oath
||Insured person may be examined by insurer under oath.
|Definition of “Catastrophic Injury”
||Catastrophic Injury includes:
- paraplegia or quadriplegia;
- Amputation or other impairment causing the total and permanent loss of use of both arms;
- Amputation or other impairment causing the total and permanent loss of use of both an arm and a leg;
- Total loss of vision in both eyes;
- Brain impairment that, in respect of an accident, results in,
- a score of 9 or less on the Glasgow Coma Scale, as published in Jennett, B. and Teasdale, G., Management of Head Injuries, Contemporary Neurology Series, Volume 20, F.A. Davis Company, Philadelphia, 1981, according to a test administered within a reasonable period of time after the accident by a person trained for that purpose, or;
- a score of 2 (vegetative) or 3 (severe disability) on the Glasgow Outcome Scale, as published in Jennett, B. and Bond, M., Assessment of Outcome After Severe Brain Damage, Lancet i:480, 1975, according to a test administered more than six months after the accident by a person trained for that purpose;
- Subject to subsection (2) and (3), any impairment or combination of impairments that, in accordance with the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993, results in 55 per cent or more impairment of the whole person, or
- Subject to subsection (2) and (3), any impairment or combination of impairments that, in accordance with theAmerican Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993, results in a class 4 impairment (marked impairment) or class 5 impairment (extreme impairment) due to mental or behavioural disorder; (“deficience invalidante”)
|Catastrophic Injury includes:
- paraplegia or quadriplegia;
- Amputation or other impairment causing the total and permanent loss of use of both arms or both legs;
- Amputation or other impairment causing the total and permanent loss of use of one or both arms and one or both legs;
- Total loss of vision in both eyes;
- Brain impairment that, in respect of an accident, results in,SameSameSame
- (1.3) Subsection (1.4) applies if an insured person is under the age of 16 years at the time of the accident and none of the Glasgow Coma Scale, the Glasgow Outcome Scale or the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993, referred to in clause (1.2) (e), (f) or (g) can be applied by reason of the age of the insured person. O. Reg. 281/03, s.1 (5)
- (1.4) For the purposes of clauses (1.2) (e), (f) and (g), an impairment sustained in an accident by an insured person described in subsection (1.3) that can reasonably be believed to be a catastrophic impairment shall be deemed to be the impairment that is most analogous to the impairment referred to in clause (1.2) (e), (f) or (g), after taking into consideration the developmental implications of the impairment. O.Reg. 281/03, s. 1(5).
|Examinations and Assessments
||Insurer to pay all reasonable expenses incurred by or on behalf of insured person for the purposes of attending an examination or assessment.
||Insurer not required to pay for an assessment unless it is reasonably required and the insurer approves the assessment.Approval is obtained by way of Application for Approval of an Assessment or Examination (OCF-22). Approval must be obtained prior to assessment except first three assessments to complete a Treatment Plan do not require prior approval if assessments cost $180 or less, where there is one assessment/provider. Also, prior approval is not required where immediate risk of harm to the individual makes obtaining prior approval impractical, or for completing a Form 1or for assessment for a determination of catastrophic impairment while insured is in hospital.Where prior approval is sought, the insurer must respond to the Assessment Plan in two business days, if the cost is $180 or less, and within five business days where the cost is more than $180. If approval is required and not sought, the insurer is not required to pay and there is no right of dispute. If approval is sought and denied, the request for assessment goes to a DAC.
|Pre-Approved Framework Guidelines
||Pre-approved treatment framework (PAF) developed for modest injuries defined as WAD I and WAD II injuries. Insured person must be assessed within 21 days following accident. Treatment plans not required unless requesting additional goods and services
|Fast Track DACs
||If a designated assessment is conducted to determine whether there are medical or rehabilitation benefits payable other than under a PAF, or the designated assessment is required because the insurer has denied all or part of an OCF-22 application (as discussed above), the DAC shall deliver its report within five days. (See Fast Track DAC intake protocol set out in the Medical and Rehabilitation Designated Assessment Centre’s DAC Assessment Manual – August 2003.)
|DAC Referral Process
||Individuals assessed by closest qualified DAC.
||Insurers can suggest DAC. If individual does not agree, Financial Services Commission appoints DAC.
||Required for insurer approval of treatment
||Required for insurer approval of treatment (goods and services)Not required for claiments in the PAF (unless request for additional goods and services not covered by PAF)
||Obligations on the Health Professional responsible for preparing and supervising the Treatment Plan:
- Secure a consent form signed by the claimant (OCF 5)
- Include all goods and services contemplated by the health professional/facility
- Ensure that there is no other coverage available or identify other coverage
- Plan must be certified by Health Practitioner as reasonable and necessary – Occupational Therapists, Nurse Practitioners and Speech-Language Pathologists are now included as “Health Practitioners” and can sign off on Treatment Plans
- Greater obligations to describe injury, sequelae and other relevant health history
- Explain consequences of releasing health information
- Incurred expenses are payable after 14 days if the insurer has not responded to the Treatment Plan
- Treatment Plan can also be used to obtain insurer approval for payment of assessments
- If the treatment Plan is denied – DAC within 5 days after selection of DAC (Insurer selects the DAC, if insured disagrees, F.S.C.O. selects the DAC)