MCI Medical Clinics Inc. - Procedure for Determining the Reasonableness of Proposed s. 24 Assessment or Examination


MCI Medical Assessments Home Page Why Choose MCI Medical Assessments? Our Services Make a Referral Contact Us Clinic Locations (PDF Map)	Procedure for Determining the Reasonableness of Proposed s. 24 Assessment or Examination The rules pertaining to the Insurer questioning the reasonableness of a proposed s.24 assessment or examination are found in sections 24, 38, 38.2, 42 and 68. Many s.24 assessments are exempt from challenge by the Insurer depending on the reason for the assessment and the cost of same. These rules are found in s. 24(1) para 1-11 and para 2 & 3 of s.24(1.2). If there is no exemption from Insurer approval for the particular assessment(s) in question, the Insured applies for approval of the assessment or examination under an OCF-18 (s.38) or an OCF-22 (s.38.2). If the application for approval of an assessment is on an OCF-18, the rules pertaining to determining the reasonableness of medical/rehabilitation expenses apply (please refer to the outline of those rules). If the application is submitted on an OCF-22, and assuming that the application does not disclose any conflict(s) of interest, the Insurer only has 3 business days to provide notice to the Insured and the person who prepared the OCF-22 which of the proposed assessments, if any, that it agrees to pay for, and/or that it will require an assessment under s. 42 if it does not approve of all the assessments proposed on the Insured's application. This notice may be given verbally, if as soon as practicable afterwards, written confirmation, on a form approved by the Superintendent of Insurance, is given to every person who received the verbal notice. 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. If the Insurer fails to give the notice within the timeframes stated above, the Insurer cannot dispute the reasonableness of any of the proposed assessment(s) on the OCF-22, but must pay for all of them without being able to have a s. 42 examination completed. Unless the notice provided under #3 above, has already provided this information, the Insurer only has a further 2 business days to provide a notice to the insured containing the following information: the reason for the s. 42 assessment the type of examination (i.e., a paper review) that a personal examination of the insured will not be conducted information as to who will conduct the examination and that person's professional qualifications and accreditations. Like the notice under #3 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. 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, with 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 pursuant to s. 42 relating to an application for approval of an assessment made under s. 38.2 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 notice in #4 above, notifying him or her of the change in the type of examination. Once again, 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. 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 a proposed assessment is reasonable. 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 #4 above. 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 #5 above. In other words, an in person examination must take place between 5 and 10 business days from the date that notice of the examination is given. 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 prepared the OCF-22 along with its determination as to whether or not it will pay for the proposed assessment(s). 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 it is not required to pay for the assessment(s) to which the s. 42 examination relates. If the Insured subsequently complies, the Insurer must reconsider the application based on the report from the s. 42 examination. Despite #13 above, the Insurer is only required to pay for all the proposed s. 24 assessments to which the s. 42 examination related if it fails to provide a copy of the report and its determination to the Insured and the person who prepared the OCF-22 on the 10th business day after all reasonably available information or documents that are relevant and necessary for a review for 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 a s. 42 assessment which relates to an application under s. 38.2 for approval of an assessment or examination. © 2006, Section 42 Assessment Consulting Inc., used with permission by MCI Medical Assessments.

Procedure for Determining the Reasonableness of Proposed s. 24 Assessment or Examination

The rules pertaining to the Insurer questioning the reasonableness of a proposed s.24 assessment or examination are found in sections 24, 38, 38.2, 42 and 68.

Many s.24 assessments are exempt from challenge by the Insurer depending on the reason for the assessment and the cost of same. These rules are found in s. 24(1) para 1-11 and para 2 & 3 of s.24(1.2).
If there is no exemption from Insurer approval for the particular assessment(s) in question, the Insured applies for approval of the assessment or examination under an OCF-18 (s.38) or an OCF-22 (s.38.2). If the application for approval of an assessment is on an OCF-18, the rules pertaining to determining the reasonableness of medical/rehabilitation expenses apply (please refer to the outline of those rules).
If the application is submitted on an OCF-22, and assuming that the application does not disclose any conflict(s) of interest, the Insurer only has 3 business days to provide notice to the Insured and the person who prepared the OCF-22 which of the proposed assessments, if any, that it agrees to pay for, and/or that it will require an assessment under s. 42 if it does not approve of all the assessments proposed on the Insured's application. This notice may be given verbally, if as soon as practicable afterwards, written confirmation, on a form approved by the Superintendent of Insurance, is given to every person who received the verbal notice. 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.
If the Insurer fails to give the notice within the timeframes stated above, the Insurer cannot dispute the reasonableness of any of the proposed assessment(s) on the OCF-22, but must pay for all of them without being able to have a s. 42 examination completed.
Unless the notice provided under #3 above, has already provided this information, the Insurer only has a further 2 business days to provide a notice to the insured containing the following information:
1. the reason for the s. 42 assessment
2. the type of examination (i.e., a paper review)
3. that a personal examination of the insured will not be conducted
4. information as to who will conduct the examination and that person's professional qualifications and accreditations.
Like the notice under #3 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.
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, with 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 pursuant to s. 42 relating to an application for approval of an assessment made under s. 38.2 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 notice in #4 above, notifying him or her of the change in the type of examination. Once again, 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. 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 a proposed assessment is reasonable. 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 #4 above.
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 #5 above. In other words, an in person examination must take place between 5 and 10 business days from the date that notice of the examination is given.
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 prepared the OCF-22 along with its determination as to whether or not it will pay for the proposed assessment(s).
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 it is not required to pay for the assessment(s) to which the s. 42 examination relates.
If the Insured subsequently complies, the Insurer must reconsider the application based on the report from the s. 42 examination.
Despite #13 above, the Insurer is only required to pay for all the proposed s. 24 assessments to which the s. 42 examination related if it fails to provide a copy of the report and its determination to the Insured and the person who prepared the OCF-22 on the 10th business day after all reasonably available information or documents that are relevant and necessary for a review for 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 a s. 42 assessment which relates to an application under s. 38.2 for approval of an assessment or examination.