Posts Tagged ‘medical’
In the decision, Larry Ward and State Farm Mutual Automobile Insurance Company [FSCO A14-010161], Arbitrator Chuck Matheson decided on a preliminary issue as to whether an insured, Mr. Larry Ward, was precluded from proceeding to arbitration on a number of issues due to his non-attendance for insurer’s examinations, which are required under Section 44 of the Statutory Accident Benefits Schedule (SABS).
One of the factors considered by Arbitrator Matheson was whether or not State Farm provided medical or other reasons for the insurer’s examinations. The arbitrator interpreted the requirement to be that, “…the medical reasons test must tell the Applicant, in an unsophisticated way, why the tests [insurer’s examinations] are reasonable and necessary.” The words “reasonable and necessary” are new to the consideration of what is required for a medical reason required by an insurer.
The decision also confirms that, just because an insurer has not approved particular treatment or an assessment (for instance, if it is funded by OHIP), does not mean that they are not required to pay for transportation to and from them. It also confirms that an OCF-18 Treatment and Assessment Plan is not required for goods or services under $250.00, as well as for medications prescribed by a regulated health professional.
Arbitrator Matheson also concluded that case management services, while subject to submission on a treatment plan, are not subject to an insurer’s examination. He notes that,
I accept the Applicant’s interpretation of section 14 that the “virtual account” called medical and rehabilitation benefits shall pay for the specified benefits listed in sections 15, 16 and 17. It does not mean, however, that section 17’s case manager benefit is in fact a Medical or Rehabilitation Benefit, per se. The legislature severed the case manager because it is not a specified Medical or Rehabilitation Benefit. The case manager’s function is to coordinate the specified benefits of sections 15 and 16 in order help the insured person to attend and claim said specified Medical/Rehabilitation and/or Attendant Care Benefits for a catastrophically impaired person.
This decision can be read in its entirety by clicking on the link below.
The Financial Services Commission of Ontario (FSCO) has announced major changes to the Statutory Accident Benefits Schedule (SABS), effective June 1, 2016.
These changes include the following:
- Medical and Rehabilitation Benefits, as well as Attendant Care Benefits, will be combined with respect to limits
- For non-catastrophic claims, the maximum will be $65,000.00 for up to five years from the date of accident
- For catastrophic claims, the maximum is $1,000,000.00, over a lifetime
- Non-Earner Benefit – $185.00 per week, payable after four weeks but only to a maximum of two years following the accident
- Catastrophic Impairment Designation – a whole new criteria for determining catastrophic impairment will be in force
FSCO has provided a new Attendant Care Hourly Rate Guideline, reflecting an increase to $11.25 per hour, effective October 1, 2015.
The Professional Services Guideline fees for 2015 remain unchanged from the previous year.
The bulletin can be read in its entirety by clicking on the link below:
Costs for Examination for CAT Assessment, Form 1 Completion and Disability Certificate Not Out of Med-Rehab Limits
A recent decision by the Financial Services Commission of Ontario (FSCO) confirms that the costs for completion of a catastrophic assessment are not subject to the medical and rehabilitation benefit limits.
In Lee-Anne Henderson and Wawanesa Mutual Insurance Company [FSCO A14-001758], Arbitrator Patrick Bowles was asked to consider whether or not this was the case. The Applicant, Ms. Henderson, had requested that the costs for the completion of a catastrophic assessment be paid by the insurer. Wawanesa denied payment, stating that Ms. Henderson had reached the maximum payable for medical and rehabilitation benefits in the amount of $50,000.00, therefore there was no further benefits available to fund the assessments.
Arbitrator Bowles accepted Ms. Henderson’s argument that the only assessments that are subject to the medical and rehabilitation benefit limits are ones for the purpose of claiming a medical and rehabilitation benefit. Since a catastrophic determination is not for the purpose of a benefit per se (rather, it is for a determination on the amount of benefits available), it is not subject to the limits, and should properly be allocated as a claims expense by the insurer.
While it was not directly considered in this decision, it follows that the costs for completion of an Attendant Care Needs Assessment (Form 1), as well as a Disability Certificate (OCF-3) are also not subject to payment under the medical and rehabilitation benefits, as they are for an attendant care benefit and for specified benefits, respectively.
If an insurer is claiming that the medical and rehabilitation benefits have reached the limits, it is helpful to obtain an itemized listing of all payments made to determine if any payments have been incorrectly allocated. This could free-up additional funds that may be needed by an insured for treatment.
This decision can be read in its entirety by clicking on the link below.
The Financial Services Commission of Ontario (FSCO) has released an updated Professional Services Guideline, which applies to expenses related to services provided by health care providers rendered on or after September 6, 2014.
A copy of the new guideline can be found at the link below.
The Financial Services Commission of Ontario (FSCO) has released two bulletins with new forms to be used for accident benefits claims, effective November 1, 2014.
The new forms include the Application for Accident Benefits (OCF-1), Treatment and Assessment Plan (OCF-18), Auto Insurance Standard Invoice (OCF-21) and the Treatment Confirmation Form (OCF-23).
In a bulletin released by FSCO it was indicated that the reason for these changes is “to improve transparency and clarity regarding data analytics and pooling of information to detect fraud. The OCF-23 has also been revised to accommodate Service Provider Licensing.”
These new forms can be downloaded at the links below:
Smitiuch Injury Law to be Gold Sponsor at Hamilton Health Sciences Centre’s 21st Annual Conference on Neurobehavioural Rehabilitation in Acquired Brain Injury
Smitiuch Injury Law is pleased to be a Gold Sponsor for this important event. It will be held on May 8 and 9, 2014, at the Hamilton Convention Centre.
We encourage all ABI Rehabilitation Professionals, Psychologists, Physicians, Program Planners, Insurance and Advocates to attend.
You can obtain a copy of the brochure by clicking on the link below:
The Financial Services Commission of Ontario (FSCO) has released a revised Minor Injury Guideline (MIG) as well as a revised Treatment and Assessment Plan (OCF-18). Both of these become effective February 1, 2014.
These revisions reflect the changes to be made to the Statutory Accident Benefits Schedule (SABS) on February 1, 2014.
To access the FSCO Bulletin, as well as the documents, click here.
Smitiuch Injury Law is pleased to host its annual seminar, entitled “Accident Benefits: Practical Issues for Health Care Professionals.” It will be held on Wednesday, September 25, 2013 at the Brantford Golf and Country Club.
The keynote topic at this year’s seminar will be on “Living With and Caring for an ABI Survivor – A Mother’s Perspective”. Bernie Perry, the mother of an acquired brain injury survivor, will identify the struggles and successes she has experienced in her daughter’s recovery and rehabilitation. Bernie will be accompanied by her case manager, Jody Abbot and Dr. Diana Velikonja, a clinical neuropsychologist at Storrie, Velikonja and Associates in Burlington.
The afternoon will also provide an update on the latest news and case law in Ontario Accident Benefits, followed by an open forum with an expert panel to answer participant’s questions. The expert panel will be composed of Ms. Heather Driver (Financial Services Commission), Tamara Forbes (Forbes Health Management), Anna-Marie Musson (Miller Thomson) and Chris Jackson (Smitiuch Injury Law).
The afternoon will begin with registration and lunch at 11:30 a.m. and will end with a cocktail reception and social at approximately 3:30 p.m.
This event is 100% complimentary.
If you wish to attend please RSVP no later than September 18, 2013 by calling 519-754-1558 or by email to [email protected].
A copy of the invitation can be accessed by clicking here.
The Financial Services Commission of Ontario (FSCO) has released an updated Professional Services Guideline for 2013.
According to the FSCO website, “The hourly rates are unchanged from the 2012 level. This is in line with the auto insurance rate reduction strategy outlined in the government’s 2013 Spring Budget.” It has also added a category for kinesiologists, who are now regulated health professionals in Ontario.
A copy of the 2013 Professional Services Guideline is available by clicking here.