Notify the insurer of intention to apply for a benefit

7 days

if accident after October 1/03

30 days

if Nov 1/96-September 30/03

If fail to notify without a reasonable explanation the insurer may delay determining if the person is entitled to a benefit for 45 days after receiving the application

Part X, Section 32

Not disentitled if the person has a reasonable explanation

Submit an application for AB’s

Within 30 days of receiving the package of forms

Section 32(3)

After notice is given, the insurer should provide a package of forms to be completed; the 30 days runs from the day you receive them

If the insurer is unable to determine if a benefit is payable because of information missing from the application

14 days to tell the insured what information is missing

S32(3.1)

Additional application or missing information

30 days after receipt of information from the insurer

No benefit is payable before the person provides the missing information

If the insurer requests additional information reasonably required to assist the insurer in determining the person’s entitlement to a benefit

14 days to provide it

No benefit is payable during the period person fails to comply

Once the person complies the insurer is to resume the benefit and pay the amounts that were withheld during the period of non compliance if there is a reasonable explanation for the delay

If the insurer requests an examination under oath

Submit at a time and place that are convenient for the person

After it is reasonable in relation to your physical, mental and emotional condition

No benefit is payable during the period person fails to comply

The insurer can resort to this only one time

The scope of the examination is limited to matters that are relevant to the person’s entitlement to benefits

The person is entitled to be represented

Provide disability certificate

21 days

No benefit is payable for the period more than 21 days after the insurer requests it and until the certificate is furnished

This form has to be completed by a physician

It applies to the income replacement benefit, caregiver, non-earner,

Housekeeping, educational expenses

It can be requested as often as reasonably necessary

Payment of income replacement benefits (Part II sections 4-11), non-earner (Part III, S12) or caregiver benefit (Part IV, S 13)

Income Replacement Benefit (IRB)

Max $400/week (except in the case of self-employed income)

Non-Earner

$185/week; payable after 26 weeks and after person is 16

if insured was a student at the time, after 104 weeks from onset of disability, goes up to $320 (12(3)

Caregiver Benefit

Where primary caregiver, not being paid

$250/wk for the 1^st person in need of care and $50/week for each addnl person

**these benefits are all subject to a disability test which changes at 104 weeks

14 days

This time goes to 45 days if you have failed to give notice in 7 days

NB any overdue payment of any benefit bears interest at 2%/month, compounded

S55 obligation to participate in treatment that will shorten the period for which this benefit is payable, provided work is available in the area and that it is “suitable” work based on “personal and vocational characteristics” (S2 defns)

S56 don’t have to work if participating in a voc rehab program

Entitlement to only one of income replacement, non-earner or caregiver

Election must be made

30 days after receiving notice to elect

It is possible to re-elect if another benefit becomes more advantageous at a later time

If insurer determines not entitled to a disability benefit, i.e. income replacement, non earner or caregiver

14 days notice that you can apply for a DAC to determine if you meet the disability test for the benefit you have applied for or are receiving

If you do not respond by requesting a DAC, your benefit will be cut off

If you do make a written request for a DAC, THE INSURER IS TO CONTINUE TO PAY PENDING THE DAC S. 37(2)3

The result of the DAC is binding; if the DAC finds that the person does not meet the disability test, the benefit will be cut off

There are further remedies through FSCO dispute resolution. Consult the SABS S37

Application for medical and rehabilitation benefit S 14-15

*NB this is now required to be signed by the patient/client

This can be refused if the person is entitled to PAF treatment at the time, but can specify treatment to be received after the PAF period

S38(2.1)(2.2)

Before incurring the expense

S38(3.1) provides that if the expense is incurred the insured has 30 days to submit a treatment plan which otherwise complies with the section

Interplay between this section and the pre-approval section not clear

This may apply to other expenses such as transportation

There are many exceptions to this requirement:

For minor injuries, certain treatment is deemed “pre-approved”. Check the Pre-Approved Framework guideline (PAF). See 37.1

Once treatment plan submitted

*need for a treatment plan can still be waived by the insurer

Insurer has to respond within 14 days S 38(8.1) (non PAF)

5 days if the insurer says the person falls within the PAF

If the insurer accepts, it has 30 days to pay from receipt of invoiceS38(11)

If the insurer disputes the treatment plan 14 days to refer to DAC, unless the insured gives notice that he/she withdraws the app (5 days)

If the insurer does not respond within 14 days, it is deemed to have approved the treatment and the treatment can commence BUT if the insurer subsequently gives notice, funding may not be available pending a DAC S38 (8.2)2

Deemed approval is a new provision under the amended SABS to attempt to correct the situation where insurers just didn’t respond to treatment plans and delayed client’s treatment

NB notice to an insurer must be addressed to the “contact person” S68(8) or it is not considered delivered

**Insurers are no longer entitled to med and rehab IE’s

Assessments and Examinations

**must be reasonably required in connection with a benefit claimed

**new S24

If requested by the insured or his/her treatment providers require pre approval by OCF 22 Application for approval of assessment or by inclusion in a treatment plan

After submission of OCF22, the insurer has 2 days to respond if cost is under $180,

5 days to respond if cost is over $180

If they don’t accept app, they have to refer to a DAC

IF THE INSURER FAILS TO RESPOND WITHIN PRESCRIBED TIME, THE REQUESTED ASSESSMENT IS DEEMED APPROVED

S24 (1.5)

S38.2(9) If the insurer fails to give the notice in time, the insurer shall pay for all assessments and examinations to which the app relates

Within 30 days (12)

Applying for approval to do an assessment is new, but after 5 business days the cost of the assessment is deemed approved

New paper review fast track

DAC to decide if “reasonably required in relation to a benefit claimed)

Assessments which are exceptions:

• WHERE THERE IS AN IMMEDIATE RISK OF HARM THAT MAKES PRE-APPROVAL IMPRACTICABLE
• Cost of assessment is less than $180 (see S. 24(1.2)2,3
• Assessment for preparing a disability certificate if less than $180
• An assessment for attendant care needs
• An assessment for completing a CAT app if the person is still in hospital
• An assessment conducted under the provisions of guideline that authorizes assessment without prior approval

No prior approval required

Submit invoice

The insured is entitled to be paid transportation expenses to and from the assessment including the expenses for an aide or an attendant where required

S24 (1.6)

NB pre-approval is not required for a Form 1 for attendant care

Attendant care S39

(1^ST app)

S2(7)

An aide or attendant can be a family member or friend even if no special qualifications

Insurer is to pay within 14 days of receiving the Form 1 (S 39 (3))

Or refer to a DAC

But even if refd to a DAC

ATTENDANT CARE IS PAY PENDING DAC s39(6)

Result of the DAC is binding subject to FSCO dispute resolution see Ins Act 279 and 233 and SABS S39 (10)

Insurer’s rights to an IE for attendant care under S42 is preserved, but on the 1^st appln, they only have 14 days to refer to the Attendant Care DAC

Attendant Care

Where there is a Change

If insd applies to increase the amount of the benefit

Insurer has to agree or refer to a DAC within 14 days 39(8)

Insurer has to pay the original amount pending the DAC

S39(11)after 104 weeks AC is only to be reviewed 1x/year

The section does not deal with change in circumstances such as post surgery care, except on agreement (12)

Application for Catastrophic

**Catastrophic defn is amended see 2(1.2) for accidents which occur on or after October 1, 2003

There is no dead line for applying for CAT but it should be done asap as it determines a tier of coverage and entitlement to a case manager

Some benefits end at 104 weeks: attendant care and housekeeping if the person is non-cat; an application for CAT should be made before the 104 weeks mark if it appears the person could meet the definition

Once application for catastrophic is made, the insurer has 30 days to respond (S40) and either accept or refer to a DAC

New provisionS40(3.1)

If an application for CAT is made before 104 weeks and referred for a DAC, THE INSURER HAS TO CONTINUE THE ATTENDANT CARE BENEFIT THAT WAS BEING PAID PENDING THE DAC

CAT DAC is binding subject to rights to resort to FSCO dispute resolution

Death and Funeral Benefits S25 and 26

Lost Educational Expenses S20

Expenses of Visitors

(for 104 weeks if non-cat and indefinite if CAT)

Housekeeping and home maintenance

($100/week for 104 weeks if non CAT and indefinite if CAT)

To be paid within 30 days of app S41

Apply for dispute resolution through FSCO

No DAC’s for these benefits

Dependent Care Benefit

Additional expenses incurred for caring for dependants due to the insured’s impairment, if the person was working at the time of the accident, is not receiving a caregiver benefit

Max $150/week see S28

Presume 30 days although not dealt with in S41

This benefit is meant for people who work but provide their own care of dependents i.e. children or an elderly person or a disabled person, who has to pay for extra services due to an impairment

Insurer Examinations

S 42

“to determine whether insured is entitled to a benefit for which an application is made”

As often as “reasonably necessary”

Upon at least 5 days notice upon a time convenient for the insured

Report has to be provided within 5 days of the insurer receiving it

Insurer can stop payment of the benefit related to the examination until the person submits to the examination

No benefit is payable in the interim unless there is a reasonably explanation for not attending

Insurers can no longer have IE’s for med and rehab

IE’s are restricted to disability, attendant care

Notice:

• In writing (S68)
• By the insurer
• Benefit has to be applied for
• Has to state which benefit the exam is in relation to

*Case managers should not be setting up IE’s

S43 Designated Assessments

*there is a new regulation governing the selection of the DAC

w/i 30 kms of the insured’s residence if in GTA or 50kms if outside GTA

insurer and insd jointly select the DAC w/in 2 days or the Superintendent shall select the DAC

Insurer to notify the DAC and provide all reasonably necessary information within 5 days

S53(9) DAC is to begin within 14 days of the request

DAC to provide a report within 14 days of the assessment completion

IF THE INSURER FAILS TO REFER TO THE DAC WITHIN 5 DAYS, 43(12) provides that the insurer has to pay for whatever benefit is subject to the DAC for the period from 5 days until the insurer notifies the DAC

If the insured does not submit, insurer may stop payment until he/she submits and no benefit is payable in the interim unless a reasonably explanation is provided

S46(e) insured is responsible for the cost of the missed appointment

S50 insured cannot resort to mediation/arbitration unless he/she has submitted to a DAC

Until October 1, the rule was the closest DAC to the insured’s residence.This new provision for joint selection will make unrepresented insured’s vulnerable

The insurer must give notice with 12 months of an alleged overpayment

If the insured is receiving IRB or caregiver, the insured can deduct 20% to repay itself the amount plus interest S47(2)