What are Med-Rehab Benefits?

Most common questions and their answers

1. What are medical-rehabilitation (“med-rehab”) benefits?

Med-rehab benefits cover the expenses, of treatment of an insured person who has been injured in a MVA, which are not covered by the Ontario Health Insurance Plan (OHIP) or a group insurance plan

A med-rehab treatment must be “reasonable” and “necessary” in order to be able to successfully claim a benefit for it (Statutory Accident Benefits Schedule or “SABS”, ss. 15 and 16)

2. Who pays for med-rehab benefits?

A claim for med-rehab benefits can be made against an insurer of a person involved in the MVA. However, one must make the claim to one’s own insurer, first, before making a claim against another insurer

3. What are the types of injuries to which med-rehab benefits pertain?

Physical and psychological injuries, including soft-tissue injuries (which are injuries to the body rather than to the hard bones). These injuries are, by nature, hard to prove because no diagnostic imaging will objectively prove them to exist.

4. What are some examples of psychological and soft-tissue injuries?

Example of psychological injuries include anxiety while driving, mood swings and post-accident chronic headaches. Examples of soft-tissue injuries include myalgia, carpal tunnel syndrome and joint pain. The nature of the injury and level of pain are based on the patient’s reports to his/her family doctor

5. What are some examples of med-rehab treatment?

Examples include acupuncture, chiropractic treatment, counseling, occupational therapy, osteopathy, physical fitness training, physiotherapy and speech therapy. There are clinics that were specifically created to treat MVA victims

6. What should I do, as soon as possible, after an accident, with respect to med-rehab?

Within days of the accident, even if there are no discernible injuries, get an opinion from your family doctor recommending med-rehab treatment

7. Who should I get a referral from for med-rehab treatment?

Some people get legal advice before getting medical advice, and get med-rehab treatment because their lawyer recommended it. However, it is better to get a referral from your family doctor because of optics – the doctor is viewed as more independent

8. What are medical benefits?

The purpose of medical benefits is to pay for medical treatment not covered by OHIP. They include:

• Dental devices lost or damaged in the MVA
• Eyewear lost or damaged in the MVA
• Medical services such as dental, optometric, home or nonhospital nursing services, ambulance, hearing tests and hearing aids and speech therapy
• Medication
• Other health services such as chiropractic services, physiotherapy, psychological assessments and counseling and occupational therapy
• Transportation to and from treatment sessions (rates are set out in the Transportation Expense Guidelines) including kilometrage and parking at medical appointments (s. 15(1))

9. What are rehabilitation benefits?

The purpose of rehabilitation benefits is to pay for treatment to return the insured person back to their ordinary activities of daily living before the MVA. They include:

• Employment counseling
• Family counseling
• Financial counseling
• Life skills training
• Social rehabilitation counseling
• Vocational and academic training
• Vocational assessments
• Workplace modifications and devices (e.g. separate room for concentration)
• Home modifications and devices (e.g. ramps)
• Transportation to and from training sessions (s. 16(1))

10. Are there caps (or “limits”) to med-rehab benefits and, if so, what are they?

There are caps and they are based on how your injury is categorized. For non-minor and catastrophic injuries, the caps apply to the total of med-rehab and attendant care benefits:

1. MIG injury → $3,500 (subject to any options you may have purchased as part of your insurance policy) (s. 18(1))
2. Non-MIG injury or injuries that are excluded from the MIG → $65,000 (s. 18(3)(a))

• Catastrophic injury → $1 million (s. 18(3)(b))

11. How are med-rehab benefits paid out?

They are not paid directly to the insured. They are paid to the third-party service provider

12. What is a MIG (or “minor”) injury?

A MIG injury means either

• a sprain – an injury to a tendon or ligament, including a partial but not a complete tear
• a strain – an injury to a muscle, including a partial but not a complete tear
• a whiplash injury – injury that occurs as a result of a sudden acceleration/deceleration
• a whiplash-associated disorder – a whiplash injury that a. does not exhibit objective, demonstrable, definable and clinically relevant neurological signs, and b. does not exhibit a fracture in or dislocation of the spine
• a contusion – viz. a bruise
• an abrasion – viz. a scrape
• a laceration – viz. an open cut/wound
• a subluxation – a partial but not a complete dislocation of a joint
• any clinically associated sequelae (s. SABS, definition section)

13. What minor injuries are excluded from the MIG?

An insured is excluded from the MIG – meaning that their med-rehab benefits are capped at $65,000 instead of $3,500 – if they have a preexisting condition that prevents them from achieving maximal recovery from their minor injury (s. 18(2))

14. What other injuries are excluded from the MIG?

Examples include a complete dislocation of a joint, a fracture (or broken bone), a dislocation of the spine and a neurological or psychological injury

15. What is the duration in which med-rehab benefits are available for a non-catastrophic injury and for where an insured does not have optional med-rehab benefits?

Five years from the date of the MVA to claim them or, if the MVA occurred when they are less than 18 years of age, until they reach the age of 28 (SABS, s. 20(1)).

16. What is the duration in which med-rehab benefits are available in respect of a catastrophic injury?

Over the course of the insured’s lifetime (SABS, s. 20(2))

17. What expenses are included in the monetary limits?

The following expenses are included in the monetary limits:

1. expenses for conducting assessments, examinations and reports conducted by the insured’s own doctors and assessors
2. fees for transportation to and from medical appointments and translation services at medical appointments.

The following expenses are not included in the monetary limits

1. Independent examinations requested by the insurer
2. Catastrophic injury designation examinations

* Tip: To help reduce the expenses that count towards your monthly limit, choose clinics where your language is spoken and attend clinics that are as close as possible to your home – to reduce transportation and translation costs

18. If I settle with the insurer, can I later claim med-rehab benefits?

Insurers often settle claims with insureds on a full and final release basis. In this case, the insured signs a full and final release on receipt of settlement funds which precludes them from further claims for med-rehab benefits in respect of the same MVA.

* Tip: In negotiating a settlement with the insurer, try to get a “Future Medicals” clause in your settlement which will allow you to claim med-rehab benefits of a value likely between zero and the unused portion of your cap.

19. Can I miss out on med-rehab benefits on a technicality?

Yes, the legislation provides that the insured must submit an OCF-18 in respect of each proposed treatment. If an OCF-18 is not submitted, the insurer is not obligated to pay.

20. Are there instances where the insurer must, on a technicality, pay med-rehab benefits?

Yes, the insurer must respond to each OCF-18 with an OCF-9 which explains what parts of the proposed treatment it agrees to pay, or not, and why. But the insurer must submit an OCF-9 within 10 business days of receipt of the OCF-18 (SABS, s. 38(8)). If they do not, they are deemed to accept the treatment plan and must pay for it (s. 38(11)).