If you have been hurt in an automobile accident and need medical and rehabilitation statutory accident benefits (“SABs”), this blog will help you understand how to ask your insurance company for benefits; what your insurance company considers when deciding whether or not to pay benefits; and what to do if your insurance company refuses to pay certain medical and rehabilitation benefits.

What are medical and rehabilitation benefits?

Medical SABs are paid by your insurance company for the purposes of covering your accident-related expenses for:

• physiotherapy;
• chiropractic therapy;
• occupational therapy;
• psychological therapy;
• hospital stays;
• wheelchairs or other mobility devices;
• prosthetics;
• medication;
• transportation to and from medical treatments; and
• other similar services.

Rehabilitation SABs are paid by your insurance company and are intended to pay for certain activities that reduce or eliminate the effects of your accident-caused disability or that help you reintegrate into your family, society, and the workforce. Such treatment includes, but is not limited to:

• life skills training;
• social rehabilitation counselling;
• financial counselling;
• employment counselling;
• vocational assessment; and
• workplace, home, and vehicle accommodations and modifications.

How to request medical and rehabilitation benefits

The payment of medical and rehabilitation benefits is not automatic. The benefits must be requested; and even then, there is no guarantee that your insurance company will pay them.

If you want your insurance company to pay expenses related to your medical or rehabilitation treatment, you cannot request the benefits yourself. You must have a health professional make the request for you.

How do you do that? It’s pretty simple.

If your physician, physiotherapist, occupational therapist, chiropractor, or other health professional thinks that you need certain medical or rehabilitation treatment because of the accident, that health professional must fill out a Treatment and Assessment Plan (“TAP”). The TAP describes your accident-caused injuries, the recommended treatment, and why and how the treatment will help you recover from your injuries. Importantly, the TAP also includes the total cost of the treatment.

Once the TAP is completed, your health professional sends it to your insurance company where it serves as the formal request for benefits.

Your health professional should have blank TAP forms at his or her office, or the forms can be found online.

How does my insurance company decide to pay (or not pay) benefits?

Your insurance adjuster will review the TAP submitted by your health professional and will consider three main factors:

• Is there enough money available to pay for the recommended treatment?
• Does the request for benefits come within the applicable timeframe for request?
• Are the expenses/treatment reasonable and necessary?

As discussed in an earlier blog, the amount of money that your insurance company can pay in medical and rehabilitation benefits is “capped” at different amounts, depending on the type of injury you suffered in the accident. There can also be a time limit for payment of benefits, depending on the type of injury.

For example: For non-catastrophic injuries the maximum amount your insurance company can pay for all medical, rehabilitation, and attendant care benefits combined is $65,000.00 and only over a maximum of 5 years. Whether the $65,000.00 is used up before the 5-year deadline, or money is left over at the 5-year mark, no further benefits are payable.

If there is enough money available to pay the benefits, and if you are not out of time to request them, the next thing your adjuster will do is consider whether or not the expenses (and the treatment itself) are “reasonable and necessary”.

Your insurance company will only pay for what it considers “reasonable and necessary” expenses. In other words, it will deny payment of any expenses that it considers unreasonable or unnecessary.

Sometimes, your adjuster will review the TAP and readily agree that the expenses (and treatment) are reasonable and necessary. He or she will then “approve” the TAP and will pay your health professional directly (per the cost indicated on the TAP). You can then receive the treatment.

In other situations, your adjuster will only partially approve the TAP. For example, your adjuster might agree to pay for in-home physiotherapy treatment, but might not agree to pay for the physiotherapist’s time to write up a report about you, or his or her travel costs.

If your adjuster refuses to pay for anything recommended on the TAP, he or she will arrange to have you assessed by a physician of your adjuster’s choosing. That physician will then provide his or her opinion on whether or not the expenses and treatment recommended by the health professional are reasonable and necessary.

Your adjuster will use the physician’s opinion to approve, partially approve, or deny the TAP.

What can I do if my insurance company refuses to pay medical and rehabilitation benefits?

If your adjuster only partially approves the TAP or completely denies the TAP on the grounds that the expenses and treatment are not reasonable or necessary, you do have options to dispute the refusal to pay benefits.

The Licence Appeal Tribunal

A lawyer can help you dispute an improper denial of medical and rehabilitation benefits. The process can be complicated. It can involve attendance at a hearing conducted by a tribunal (the Licence Appeal Tribunal) that will consider your claim for benefits versus your insurance company’s denial of benefits. After hearing arguments from your lawyer and from the lawyer representing your insurance company, the tribunal will make a decision as to whether or not you are entitled to the benefits.

Other Options

The drawback to proceeding to a tribunal for a decision is the “wait” it involves. The tribunal can be backlogged and it can take months to get a hearing and receive a decision. Often during this time, an injured person goes without treatment because there is no money to pay for it.

There are options to receive treatment while in the process of fighting your insurance company on its denial (and even if you have simply reached the monetary limit of your SABS coverage but still require further treatment):

• Treatment loans: There are financing companies that will loan you money so that you can pay for your treatment. The money must be used to fund your treatment and is usually managed by your lawyer, who pays your treatment provider (i.e. physiotherapist, chiropractor, etc.) directly. These loans can carry relatively high interest rates and, when your lawsuit is over, your settlement funds are used to pay back the loan. The loan must be paid back in full, with interest, before you can receive any of your settlement money.
   
• Holding an account until settlement: Some treatment providers will agree to treat you without being paid right away, if you sign an agreement that they will be paid once your lawsuit settles. The agreement will state that your lawyer will pay the treatment provider’s invoice out of your settlement funds before giving any settlement funds to you.
   
• Direction to Pay: If your treatment provider requires immediate payment for his or her services, your lawyer might agree to fund your treatment. A “Direction to Pay” is a document signed by you and your lawyer agreeing that your lawyer will be paid back when your lawsuit is over. Your lawyer will be paid out of your settlement funds before any of the funds are delivered to you.

If your insurance company has refused to pay medical and rehabilitation benefits that have been recommended for you, we can help you. A consultation with a lawyer from our office is free. Call us at 519-946-4300.

This article is not a substitute for legal advice.

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