MCI Medical Clinics Inc. - Procedure for Determining Initial Entitlement to a Specified Benefit


MCI Medical Assessments Home Page Why Choose MCI Medical Assessments? Our Services Make a Referral Contact Us Clinic Locations (PDF Map)	Procedure for Determining Initial Entitlement to a Specified Benefit (Income Replacement Benefits, Non-Earner Benefits, Caregiver Benefits or Housekeeping and Home Maintenance Benefits) The rules pertaining to an initial determination of entitlement to a specified benefit can be found in sections 35, 42, 42.1 and 68. The Insured submits an application including an OCF-3 to the Insurer. Within 10 days of receiving the application, the Insurer must either: pay the benefit, or request any information necessary to complete the application, or notify the Insured in writing, on a form approved by the Superintendent of Insurance that the Insurer requires an examination under s. 42 to assist with the determination as to whether the Insured person is entitled to receive a specified benefit. Unless the notice under #2(iii) has already provided this information, the Insurer hasa further 5 business days to provide the Insured with the following information: the reason(s) for the examination the type of examination that will be conducted that the examination will include a personal examination of the Insured information on who will conduct the examination and their professional accreditations the day, time, location and anticipated length of time of the examination. 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. 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 with 30 kms of his or her residence if he or she resides in Toronto, Peel, Durham, Halton or York, or within 50 kms, if he or she resides elsewhere. The notice under #3 above, cannot be given less that 5 business days before the examination unless the Insured agrees to a shorter notice. The examination must be completed not more the 10 business days after notice of the assessment is given. In other words the examination must be completed between the 5th and 10th day after the notice of the examination, under #3 above, is given to the Insured. This is at most 25 business days after the Insurer receives the application (including OCF-3) for the specified benefit. Within 5 business days after the notice of the assessment is given under #3 above, 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. The report must be completed by the assessor and given to Insurer not later than 10 business days after the examination was completed. The Insurer has 5 business days after receiving the report from the s. 42 assessor to provide a copy to the Insured and his or her health practitioner who completed the OCF-3, together with a determination of entitlement to the specified benefit and the reasons for the determination. No benefit is payable pending this determination of entitlement provided all steps are followed and time frames are observed. If the 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 fails to attend at 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 a specified benefit. If the Insured subsequently complies, the Insurer must reconsider the application based on the s. 42 examination, and if the Insurer determines that the insured person is entitled to receive the specifed benefit, the Insurer must pay all amounts which were withheld during the period of non-compliance, provided that not later than 10 business days after his or her failure or refusal to comply, or as soon as practicable thereafter, the Insured person provides a reasonable explanation. Notwithstanding #9 above, the Insurer is only required to commence paying specified benefits to the Insured person if it fails to provide a copy of the report from the s. 42 examination, together with its determination of entitlement, within 15 days after the examination was completed or was required to be completed (i.e., not later than 10 days after the notice was given under #3 above). This presupposes that that the Insured person has not failed to comply with the requirements 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, and to attend for the examination and to submit to all reasonable physical, psychological, mental and functional examinations requested by the person conducting the examination. If the Insurer determines that no benefit is payable, the insured person can then require Insurer to pay for his or her own assessment to rebut the s. 42 examination, subject to the following: the assessment is conducted and the report is provided to the Insurer not more then 40 business days after the Insurer provided the s. 42 report and its denial to the Insured the assessment must be conducted by the original provider who completed the OCF-3 (likely a general practitioner) unless the original provider is not a member of the same health profession or specialty as the s. 42 assessor the fee cannot be more than $775.00 if the assessment to rebut the s. 42 report is conducted by someone other than a physician with a specialty which is not family medicine (in which case the fee can be as much as $900.00) Note that the Insurer is not required to pay or re-instate a benefit on the basis of a rebuttal assessment. The purpose of the rebuttal assessment is to assist in dispute resolution in accordance with sections 280 to 283 of the Insurance Act. © 2006, Section 42 Assessment Consulting Inc., used with permission by MCI Medical Assessments.

Procedure for Determining Initial Entitlement to a Specified Benefit (Income Replacement Benefits, Non-Earner Benefits, Caregiver Benefits or Housekeeping and Home Maintenance Benefits)

The rules pertaining to an initial determination of entitlement to a specified benefit can be found in sections 35, 42, 42.1 and 68.

The Insured submits an application including an OCF-3 to the Insurer.
Within 10 days of receiving the application, the Insurer must either:
1. pay the benefit, or
2. request any information necessary to complete the application, or
3. notify the Insured in writing, on a form approved by the Superintendent of Insurance that the Insurer requires an examination under s. 42 to assist with the determination as to whether the Insured person is entitled to receive a specified benefit.
Unless the notice under #2(iii) has already provided this information, the Insurer hasa further 5 business days to provide the Insured with the following information:
1. the reason(s) for the examination
2. the type of examination that will be conducted
3. that the examination will include a personal examination of the Insured
4. information on who will conduct the examination and their professional accreditations
5. the day, time, location and anticipated length of time of the examination.
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.
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 with 30 kms of his or her residence if he or she resides in Toronto, Peel, Durham, Halton or York, or within 50 kms, if he or she resides elsewhere.
The notice under #3 above, cannot be given less that 5 business days before the examination unless the Insured agrees to a shorter notice.
The examination must be completed not more the 10 business days after notice of the assessment is given. In other words the examination must be completed between the 5th and 10th day after the notice of the examination, under #3 above, is given to the Insured. This is at most 25 business days after the Insurer receives the application (including OCF-3) for the specified benefit.
Within 5 business days after the notice of the assessment is given under #3 above, 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.
The report must be completed by the assessor and given to Insurer not later than 10 business days after the examination was completed.
The Insurer has 5 business days after receiving the report from the s. 42 assessor to provide a copy to the Insured and his or her health practitioner who completed the OCF-3, together with a determination of entitlement to the specified benefit and the reasons for the determination.
No benefit is payable pending this determination of entitlement provided all steps are followed and time frames are observed.
If the 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 fails to attend at 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 a specified benefit.
If the Insured subsequently complies, the Insurer must reconsider the application based on the s. 42 examination, and if the Insurer determines that the insured person is entitled to receive the specifed benefit, the Insurer must pay all amounts which were withheld during the period of non-compliance, provided that not later than 10 business days after his or her failure or refusal to comply, or as soon as practicable thereafter, the Insured person provides a reasonable explanation.
Notwithstanding #9 above, the Insurer is only required to commence paying specified benefits to the Insured person if it fails to provide a copy of the report from the s. 42 examination, together with its determination of entitlement, within 15 days after the examination was completed or was required to be completed (i.e., not later than 10 days after the notice was given under #3 above). This presupposes that that the Insured person has not failed to comply with the requirements 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, and to attend for the examination and to submit to all reasonable physical, psychological, mental and functional examinations requested by the person conducting the examination.
If the Insurer determines that no benefit is payable, the insured person can then require Insurer to pay for his or her own assessment to rebut the s. 42 examination, subject to the following:
1. the assessment is conducted and the report is provided to the Insurer not more then 40 business days after the Insurer provided the s. 42 report and its denial to the Insured
2. the assessment must be conducted by the original provider who completed the OCF-3 (likely a general practitioner) unless the original provider is not a member of the same health profession or specialty as the s. 42 assessor
3. the fee cannot be more than $775.00 if the assessment to rebut the s. 42 report is conducted by someone other than a physician with a specialty which is not family medicine (in which case the fee can be as much as $900.00)
Note that the Insurer is not required to pay or re-instate a benefit on the basis of a rebuttal assessment. The purpose of the rebuttal assessment is to assist in dispute resolution in accordance with sections 280 to 283 of the Insurance Act.
© 2006, Section 42 Assessment Consulting Inc., used with permission by MCI Medical Assessments.