How does one apply for Medical-Rehabilitation and Attendant Care Benefits?

Discover the procedure for Med-Rehab and AC applications

Although we will consider qualification criteria in more detail in further blog posts, here we will consider the procedure for applying for accident benefits.

1. Medical-rehabilitation (aka med-rehab) benefits

The insured must apply for benefits under other policies first (e.g. short-term disability/long-term disability benefits, work insurance, etc.).

The form used depends on whether the insured’s injury is catastrophic, non-catastrophic or minor. If the injury is either catastrophic or non-catastrophic, the “Treatment and Assistance Plan” (OCF-18) must be completed and submitted. If the injury is minor, the “Treatment Confirmation Form” (OCF-23) must be. These forms contain information about what goods, services, assessments and examinations the health practitioner approves. In addition, documentation confirming a preexisting condition (if applicable) is required.

• If an OCF-18 has been completed and submitted to the insurer, then, within 10 days of receipt, the insurer will provide an “Explanation of Benefits Form” (OCF-9) explaining what goods, services, assessments and examinations it agrees to pay and which it refuses to pay and reasons and whether the insurer believes that the Minor Injury Guidelines (or MIG) applies to the applicant
• If the insurer does not pay for all goods, services, assessments and examinations, or believes that the MIG applies, the notice may tell the applicant to attend an independent medical examination (or IME)
• If the insurer does not provide proper notice, that the MIG applies, within the 10-day time limit, it must pay for all goods, services, assessments and examinations the applicant requested
• If the IME occurs, the insurer must provide the applicant with a copy of the report within 10 days of receipt
• If the IME occurs, within 10 days of receipt, the insurer must provide notice of what goods, services, assessments and examinations the insurer agrees to pay for, or whether the insurer believes that the MIG applies
• The insurer shall pay for goods and services the insurer agreed to pay for in the notice or is required to pay for under SABS within 30 days after receiving an invoice for them
• If the insurer believes that the MIG applies to the applicant, the applicant may choose to have an OCF-23 completed and submitted within 10 days of the initial visit for treatment unless the insurer has waived this requirement
• Within five days of receipt of the OCF-23, the insurer must provide notice acknowledging receipt and advising whether the applicant is an insured person with respect to the accident
• If the insurer accepts the OCF-23, it will, within 30 days of receipt, pay every invoice for goods and services within the MIG Guidelines

B: Attendant care (aka AC) benefits

AC benefits available through other sources must be accessed first. An expense must be incurred to qualify as being an attendant-care benefit. For an expense to be “incurred”, a) the expense must have been received by the insured, b) the insured must have paid or promised to pay for the service and c) the person who provided the service must be ordinarily employed as an aide or attendant or experienced an economic loss as a result of providing the insured’s care. An economic loss is defined as a financial, monetary or wage loss, and does not include merely a loss of time (Simser v. Aviva Canada and FSCO (Divisional Court 2015)). Compensation is paid to the extent of the economic loss and not at the Form 1 rate. Family members may qualify to receive AC benefits but proof of economic loss is required. A stay-at-home parent does not qualify.

• If there is no alternative for care, an occupational therapist or registered nurse will complete an “Assessment of Attendant Care Needs” (Form 1)
• Within 10 days of receipt, the insurer will provide a notice indicating what expenses it agrees to pay and which it refuses to pay and reasons and may require attendance for an IME
• Payment begins within 10 days of the insurer’s receipt of the Form 1 and pending the examination report and the amount shall be calculated based on assessment of attendant care needs (usually based on Form 1 or examination)
• Within 10 days of receipt of a first or later examination report, the insurer must provide the insured with a copy and with notice specifying the benefits and expenses it agrees to pay, those it refuses to pay and reasons
• Subsequent Form 1s and IMEs may be requested and required by the insurer to determine continued entitlement to AC benefits. Once these notices are received, a Form 1 must be completed and submitted within 15 days
• Supporting documentation such as receipts, invoices, details of service provided, number of hours spent, the hourly rate of the service provider and proof that an expense was incurred must also be provided to the insurer

If med-rehab and AC benefits are cancelled or reduced, that can be legally challenged. Contact Azimi Law if you seek help applying for these benefits or if you are contesting their cancellation or reduction.

How does one apply for Income Replacement, Non-Earner and Caregiver Benefits?

The procedures for IRB, NEB and CGB applications are explained

Election: If the insured’s application indicates that he/she may qualify for one or more of – IRBs, NEBs or CGBs – then the insurer must provide a notice that the insured needs to state which benefits he/she wishes to receive (“Election of Income Replacement, Non-Earner or Caregiver Benefit Form”, OCF-10).

Note that this election is final (SABS, s. 35(3)) with one exception. If the insured is determined to have had a catastrophic injury as a result of the accident, he/she can reelect to receive CGBs within a 30-day period (s. 35(2)). Case law used to allow for further exceptions but they were cancelled via statutory amendment effective Feb 1, 2014.

Termination of benefits: Eventually, the insurer will ask the insured to complete a Disability Certificate or attend an examination and make the determination to stop the benefit(s). If this determination is made, the insurer must provide notice + reasons.

Contesting insurer’s decisions: If the AB insurer decides to reject proposed benefit(s) or decides to discontinue them, the insured can enter into mediation to resolve the dispute within two years of the date of denial and thereafter can commence a court claim.