MCI Medical Clinics Inc. - Procedure to Determine Whether Insured Has a WAD


MCI Medical Assessments Home Page Why Choose MCI Medical Assessments? Our Services Make a Referral Contact Us Clinic Locations (PDF Map)	Procedure for Determining Whether an Insured Has an Impairment to Which a Pre-approved Framework Guideline Applies The rules pertaining to a determination as to whether an Insured has an impairment to which a pre-approved framework guideline applies are found in sections 38, 42 and 68 of the Statutory Accident Benefits Schedule - Accidents On or After November 1, 1996. The Insured submits an OCF-18 to the Insurer seeking treatment outside that provided for under a Pre-approved Framework Guideline. If the Insurer believes that the Insured has an impairment to which a Pre-approved Framework Guideline applies it must within 5 business days of receiving the OCF-18, provide the Insured with written notice stating that it believes the Insured has and impairment to which a Pre-approved Framework Guideline applies, and requiring the Insured to be examined under s. 42 to assist the Insurer in determining whether the Insured has and impairment to which a Pre-approved Framework Guideline applies. This notice is to be given on a form approved by the Superintendent of Insurance. The notice may be delivered by fax to a person or his solicitor or authorized representative, or by personal delivery, by certified or registered mail, but not by regular letter mail. If the Insurer fails to give the notice within the timeframe stated above, it can no longer reject the proposed Treatment Plan on the basis that the Insured has an impairment to which a Pre-approved Framework Guideline applies. However, it would still be possible for the Insurer to dispute the reasonableness of the proposed treatment. An Insured who receives a notice under #2 above, can submit a Treatment Confirmation Form (OCF-23) and may receive goods and services in accordance with the PAF while the dispute over whether they have an impairment which is outside the PAF is pending. Note that this does not mean that the Insurer is no longer required to arrange for the examination under s. 42. Unless the notice under #2 has already provided this information, the Insurer only has a further 2 business days to notify the Insured of the following: the reason for the examination the type of examination and, unless #5 below applies, that the attendance of the Insured will not be required that a personal examination of the Inured will not be conducted information on who will conduct the examination and their professional qualifications and accreditations. This notice may be given verbally, if written confirmation, on a form approved by the Superintendent of Insurance is given as soon as practicable afterwards. Again, this written notice may be delivered by fax to a person or his solicitor or authorized representative, by personal delivery, by certified or registered mail, but not by regular letter mail. While it is not specifically stated as a requirement, we would suggest that the notice from the Insurer also contain a statement to the effect that the Insured must, within 5 business days from the time he or she receives notice of the examination, provide to the person conducting the examination, all reasonably available information and documents that are relevant or necessary for the review of his or her medical condition. It is important to note that an assessment under s. 42 relating to whether an Insured has an impairment to which a Pre-approved Framework Guideline applies is limited to an examination of material provided by the Insurer and the Insured under s. 42(10) without the attendance of or a personal examination of the Insured (i.e. a paper review), unless it is determined by the person conducting the examination, that the Insured should be in attendance in order to be personally examined. However, the Insurer will have to provide the Insured with a revised notice within 2 business days of the initial notice, notifying him or her of the change in the type of examination. As was the case with the notice under #4 above, this notice may be given verbally, if written confirmation, on a form approved by the Superintendent of Insurance is given as soon as practicable afterwards. Again, this written notice may be delivered by fax to a person or his solicitor or authorized representative, by personal delivery, by certified or registered mail, but not by regular letter mail. Note that this is a very onerous requirement, which is designed to prevent the Insurer from having an actual in person assessment of the Insured for the purpose of determining whether an Insured person has an impairment to which a Pre-approved Framework Guideline applies. In practice, it will be difficult for an Insurer to comply with this requirement. If #5 above applies, the revised notice (which, as stated above, must be given to the Insured within 2 business days of the previous notice) must notify the Insured of the following: that the type of examination has been changed that his or her attendance will be required the day, time, location and anticipated length of time of the examination The notice required under #4 or #5 cannot be given less than 5 business days before the examination unless the Insured agrees to a shorter notice period. If the attendance of the Insured is required for the examination (i.e., because #5 above applies), the Insurer must make reasonable efforts to schedule the examination for a time that is convenient for the Insured, and unless the Insured consents otherwise, at a location within 30 kms of his or her residence if he or she resides in Toronto, Peel, Durham, Halton or York, or within 50 kms of his or her residence if he or she resides elsewhere. Within 5 business days after the notice of the assessment is given, the Insurer and the Insured are to provide to the assessor, all relevant prior test and examination results and such other information and documents as are relevant or necessary for a review of the insured person's medical condition. If the attendance of the Insured is not required for the examination, the examination must be completed and a copy of the report provided to the Insurer not more than 5 business days after the notice of the examination is provided under #5. Note that this is the same day the Insurer and Insured are required to provide information to the assessor under s. 42(10). If the attendance of the Insured is required for the examination, the examination must be completed not more than 10 business days after the notice of the examination is provided under #6. The report from an examination under #11 must be provided by the assessor to the Insurer not later than 10 business days after the examination is completed. The Insurer has 5 business days after receiving the report to provide a copy to the Insured and the person who approved the OCF-18 along with a determination as to whether the Insured person has an impairment to which a Pre-approved Framework Guideline applies, and the reason(s) for that determination. If an Insured fails to provide to the person conducting the examination, all reasonably available information or documents that are relevant and necessary for a review of his or her medical condition, or if his or her attendance is required at the examination and he or she fails to attend the examination, or does not submit to all reasonable physical, psychological, mental and functional examinations requested by the person conducting the examination, the Insurer may make a determination that the Insured person is not entitled to the goods and services contemplated by the OCF-18. If the insured subsequently complies, the Insurer must reconsider the application based on the s. 42 examination. Despite #13 above, the Insurer is only precluded from taking the position that the Insured person has an impairment to which a Pre-approved Framework Guideline applies if it fails to provide a copy of the report and its determination to the Insured and the person who prepared the OCF-18 on the 10th business day after all reasonably available information or documents that are relevant and necessary for a review of the Insured's medical condition was provided to the person conducting the s. 42 examination if the Insured's attendance was not required, or on the 15th business day after the s. 42 examination was completed if the attendance of the Insured was required for the examination. Section 42.1 (which allows the Insured to have the Insurer pay for a rebuttal assessment) is not available to challenge an s. 42 assessment which relates to a determination as to whether an Insured has an impairment to which a Pre-approved Framework Guideline applies or not. © 2006, Section 42 Assessment Consulting Inc., used with permission by MCI Medical Assessments.

Procedure for Determining Whether an Insured Has an Impairment to Which a Pre-approved Framework Guideline Applies

The rules pertaining to a determination as to whether an Insured has an impairment to which a pre-approved framework guideline applies are found in sections 38, 42 and 68 of the Statutory Accident Benefits Schedule - Accidents On or After November 1, 1996.

The Insured submits an OCF-18 to the Insurer seeking treatment outside that provided for under a Pre-approved Framework Guideline.
If the Insurer believes that the Insured has an impairment to which a Pre-approved Framework Guideline applies it must within 5 business days of receiving the OCF-18, provide the Insured with written notice stating that it believes the Insured has and impairment to which a Pre-approved Framework Guideline applies, and requiring the Insured to be examined under s. 42 to assist the Insurer in determining whether the Insured has and impairment to which a Pre-approved Framework Guideline applies. This notice is to be given on a form approved by the Superintendent of Insurance. The notice may be delivered by fax to a person or his solicitor or authorized representative, or by personal delivery, by certified or registered mail, but not by regular letter mail.
If the Insurer fails to give the notice within the timeframe stated above, it can no longer reject the proposed Treatment Plan on the basis that the Insured has an impairment to which a Pre-approved Framework Guideline applies. However, it would still be possible for the Insurer to dispute the reasonableness of the proposed treatment.
An Insured who receives a notice under #2 above, can submit a Treatment Confirmation Form (OCF-23) and may receive goods and services in accordance with the PAF while the dispute over whether they have an impairment which is outside the PAF is pending. Note that this does not mean that the Insurer is no longer required to arrange for the examination under s. 42.
Unless the notice under #2 has already provided this information, the Insurer only has a further 2 business days to notify the Insured of the following:
1. the reason for the examination
2. the type of examination and, unless #5 below applies, that the attendance of the Insured will not be required
3. that a personal examination of the Inured will not be conducted
4. information on who will conduct the examination and their professional qualifications and accreditations.
This notice may be given verbally, if written confirmation, on a form approved by the Superintendent of Insurance is given as soon as practicable afterwards. Again, this written notice may be delivered by fax to a person or his solicitor or authorized representative, by personal delivery, by certified or registered mail, but not by regular letter mail.
While it is not specifically stated as a requirement, we would suggest that the notice from the Insurer also contain a statement to the effect that the Insured must, within 5 business days from the time he or she receives notice of the examination, provide to the person conducting the examination, all reasonably available information and documents that are relevant or necessary for the review of his or her medical condition.
It is important to note that an assessment under s. 42 relating to whether an Insured has an impairment to which a Pre-approved Framework Guideline applies is limited to an examination of material provided by the Insurer and the Insured under s. 42(10) without the attendance of or a personal examination of the Insured (i.e. a paper review), unless it is determined by the person conducting the examination, that the Insured should be in attendance in order to be personally examined. However, the Insurer will have to provide the Insured with a revised notice within 2 business days of the initial notice, notifying him or her of the change in the type of examination. As was the case with the notice under #4 above, this notice may be given verbally, if written confirmation, on a form approved by the Superintendent of Insurance is given as soon as practicable afterwards. Again, this written notice may be delivered by fax to a person or his solicitor or authorized representative, by personal delivery, by certified or registered mail, but not by regular letter mail.
Note that this is a very onerous requirement, which is designed to prevent the Insurer from having an actual in person assessment of the Insured for the purpose of determining whether an Insured person has an impairment to which a Pre-approved Framework Guideline applies. In practice, it will be difficult for an Insurer to comply with this requirement.
If #5 above applies, the revised notice (which, as stated above, must be given to the Insured within 2 business days of the previous notice) must notify the Insured of the following:
1. that the type of examination has been changed
2. that his or her attendance will be required
3. the day, time, location and anticipated length of time of the examination
The notice required under #4 or #5 cannot be given less than 5 business days before the examination unless the Insured agrees to a shorter notice period.
If the attendance of the Insured is required for the examination (i.e., because #5 above applies), the Insurer must make reasonable efforts to schedule the examination for a time that is convenient for the Insured, and unless the Insured consents otherwise, at a location within 30 kms of his or her residence if he or she resides in Toronto, Peel, Durham, Halton or York, or within 50 kms of his or her residence if he or she resides elsewhere.
Within 5 business days after the notice of the assessment is given, the Insurer and the Insured are to provide to the assessor, all relevant prior test and examination results and such other information and documents as are relevant or necessary for a review of the insured person's medical condition.
If the attendance of the Insured is not required for the examination, the examination must be completed and a copy of the report provided to the Insurer not more than 5 business days after the notice of the examination is provided under #5.
Note that this is the same day the Insurer and Insured are required to provide information to the assessor under s. 42(10).
If the attendance of the Insured is required for the examination, the examination must be completed not more than 10 business days after the notice of the examination is provided under #6.
The report from an examination under #11 must be provided by the assessor to the Insurer not later than 10 business days after the examination is completed.
The Insurer has 5 business days after receiving the report to provide a copy to the Insured and the person who approved the OCF-18 along with a determination as to whether the Insured person has an impairment to which a Pre-approved Framework Guideline applies, and the reason(s) for that determination.
If an Insured fails to provide to the person conducting the examination, all reasonably available information or documents that are relevant and necessary for a review of his or her medical condition, or if his or her attendance is required at the examination and he or she fails to attend the examination, or does not submit to all reasonable physical, psychological, mental and functional examinations requested by the person conducting the examination, the Insurer may make a determination that the Insured person is not entitled to the goods and services contemplated by the OCF-18.
If the insured subsequently complies, the Insurer must reconsider the application based on the s. 42 examination.
Despite #13 above, the Insurer is only precluded from taking the position that the Insured person has an impairment to which a Pre-approved Framework Guideline applies if it fails to provide a copy of the report and its determination to the Insured and the person who prepared the OCF-18 on the 10th business day after all reasonably available information or documents that are relevant and necessary for a review of the Insured's medical condition was provided to the person conducting the s. 42 examination if the Insured's attendance was not required, or on the 15th business day after the s. 42 examination was completed if the attendance of the Insured was required for the examination.
Section 42.1 (which allows the Insured to have the Insurer pay for a rebuttal assessment) is not available to challenge an s. 42 assessment which relates to a determination as to whether an Insured has an impairment to which a Pre-approved Framework Guideline applies or not.