MCI Medical Clinics Inc. - Procedure for Determining Benefits are Reasonable


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 Medical and/or Rehabilitation Benefits are Reasonable and Necessary The rules pertaining to a determination as to whether medical and/or rehabilitation benefits are reasonable and necessary can be found in sections 38, 42, and 68. These rules do not apply to medical benefits for which the Insured person submits an application under a Pre-approved Framework Guideline. However, they do apply to an application for the payment of an assessment or examination under s. 24, if the application is submitted on an OCF-18 (Treatment Plan), as opposed to an OCF-22 (Application for the Approval of an Assessment or Examination). If the application pertains to an assessment or examination under an OCF-22, please see the Rules for Determining the Reasonableness of Proposed s. 24 Assessments or Examinations. Note that except for emergency goods and services, such as ambulance expenses, etc., incurred within 5 business days after the accident, the Insurer is not liable to pay for any expense to which s. 38 relates, which was incurred before the Insured person submits and application for the expense which includes a Treatment Plan (OCF-18). Note as well, that an Insured person may not submit an OCF-18 for goods and services that will be provided at the same time as her or she is being treated under a Pre-approved Framework Guideline. The Treatment Plan submitted by the Insured person must disclose any conflict(s) of interest that any of the following have in relation to the Treatment Plan: the person who prepared the Treatment Plan, or any person who referred the Insured person to a person who will provide goods or services under the Treatment Plan. Additionally, a lawyer or other representative who acts for the Insured person must provide notice of any conflict of interest that he or she has in relation to the Treatment Plan. Upon receipt of a Treatment Plan where the Insured person has declared no conflict(s) of interest, the Insurer must do one of the following: within 10 days of receipt of the Treatment Plan, provide the Insured person with written notice on a form approved by the Superintendent of Insurance, that describes any conflict of interest that the Insurer has in relation to the Treatment Plan, describes the goods and services, if any, that are contemplated by the Treatment, and which the Insurer agrees to pay for, and requiring the Insured person to be assessed under s. 42 in relation to any goods or services which the Insurer does not agree to pay for, or within 5 business days of receipt of the Treatment Plan, provide the Insured person with written notice on a form approved by the Superintendent of Insurance, stating that the insurer believes that the Insured person has an impairment to which a Pre-approved Framework Guideline applies, and requiring the Insured person to be examined under s. 42 to assist with the determination as to whether the Insured person should be treated in accordance with a PAF. If #4 b) applies, please refer to the *Rules for Determining Whether an Insured Has an Impairment to Which a Pre-approved Framework Guideline* Applies. The remainder of this particular set of rules pertains only to the notice contemplated in #4 a) above. Note that under #4 a), there are two possible scenarios. The Insurer may dispute the proposed Treatment Plan, or parts of it because it believes that the proposed treatment is not reasonable or necessary for the injuries sustained in the accident, in which case #5 - 15 below, apply. Or, if appropriate, the Insurer may dispute the proposed Treatment Plan on the basis that the goods and services contemplated by the Treatment Plan are substantially similar to goods and services which the Claimant has previously submitted on a previous Treatment Plan in respect of the same accident, which the Insurer has refused to pay for. In this situation, which by definition can only arise when the Claimant is re-submitting an application for treatment that has been determined not to be reasonable and necessary as a result of a previous s. 42 examination, please refer to the Rules Respecting a Previously Denied Treatment Plan. If the Insurer is late providing the notice required by #4 a) above, the insurer must pay for all goods and services provided under the Treatment Plan during the period commencing on the 11th business day after the Insurer receives the completed application, and ending on the day the Insurer provides the required notice. Unless the notice under #4 a) has already provided this information, the Insurer has a 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 (in this case involving the attendance and a personal examination of the Insured) 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 may be given verbally, if written confirmation on a form approved by the Superintendent of Insurance is given as soon as practicable afterwards. The written notice may be delivered by fax to a person or his solicitor or authorized representative, or bypersonal 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 #6 above, cannot be given less than 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 unless the Insured person has sustained a catastrophic impairment, in which case the examination must be completed within 30 days. In other words (unless the Insured has a catastrophic impairment), the examination must be completed between the 5th and 10th day after the notice of the examination, under #6 above, is given to the Insured. Within 5 business days after the notice of the assessment is given under #6 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 providea copy to the Insured and his or her health practitioner who completed the OCF-18, together with a determination as to which goods and services which were the subject of the s. 42 assessment that the Insured agrees to pay for and which goods and services the Insurer refuses to pay for together with the reasons for the decision. 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 hisor 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 the goods and services contemplated by the Treatment Plan. If the Insured subsequently complies, the Insurer must reconsider the application based onthe report from the s. 42 examination. Notwithstanding #12 above, the Insurer is only required to commence paying for the goods and services contemplated by the Treatment Plan, if the Insurer fails to provide the Insured person and his health practitioner with a copy of the report from the s. 42 examination together with its determination of entitlement 15 business days after the s. 42 examination was required to be completed in accordance with #9 above. In other words, the report and determination must be provided not later than 25 business days** after the notice of the s. 42 examination is given to the Insured person.Of course, if the determination of the Insurer is that it is not required to pay for the goods and services contemplated by the Treatment Plan, it is only obligated to pay for those goods and services received by the Insured person during the period commencing on the day referred to in the previous paragraph, and ending on the day it does provide a copy of the report and its determination to the Insured person. If the Insurer determines that the Insured person is not entitled to any of the benefits contemplated by the Treatment Plan he or she can then require the 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 than 40 business days after the Insurer provided the s. 42 report and its denial to the Insured if the Insured has not sustained a catastrophic impairment (in which case this timeframe is extended to 80 business days) the assessment must be conducted by the original provider who approved the OCF-18 unless that original provider is not a member of the same health profession or specialty as the s. 42 assessor if the s. 42 assessor and the original provider who approved the OCF-18 are members of the same health profession, or same specialty if the original provider is authorized to practice in a specialty, the rebuttal assessment is limited to a review of the paper file which was provided to the s. 42 assessor by the parties the rebuttal assessment would also be limited to a review of the paper file which was provided to the s. 42 assessor if the rebuttal assessment is the second one in a 12 month period pertaining to medical and rehabilitation benefits the fee for the rebuttal assessment 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), unless the rebuttal assessment is limited to a paper review, in which case the fee may not be more than $450. Note that the Insurer is not required to pay a medical or rehabilitation benefit which it has denied 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 whether Medical and/or Rehabilitation Benefits are Reasonable and Necessary

The rules pertaining to a determination as to whether medical and/or rehabilitation benefits are reasonable and necessary can be found in sections 38, 42, and 68. These rules do not apply to medical benefits for which the Insured person submits an application under a Pre-approved Framework Guideline. However, they do apply to an application for the payment of an assessment or examination under s. 24, if the application is submitted on an OCF-18 (Treatment Plan), as opposed to an OCF-22 (Application for the Approval of an Assessment or Examination). If the application pertains to an assessment or examination under an OCF-22, please see the Rules for Determining the Reasonableness of Proposed s. 24 Assessments or Examinations.

Note that except for emergency goods and services, such as ambulance expenses, etc., incurred within 5 business days after the accident, the Insurer is not liable to pay for any expense to which s. 38 relates, which was incurred before the Insured person submits and application for the expense which includes a Treatment Plan (OCF-18).
Note as well, that an Insured person may not submit an OCF-18 for goods and services that will be provided at the same time as her or she is being treated under a Pre-approved Framework Guideline.
The Treatment Plan submitted by the Insured person must disclose any conflict(s) of interest that any of the following have in relation to the Treatment Plan:
1. the person who prepared the Treatment Plan, or
2. any person who referred the Insured person to a person who will provide goods or services under the Treatment Plan.
Additionally, a lawyer or other representative who acts for the Insured person must provide notice of any conflict of interest that he or she has in relation to the Treatment Plan.
Upon receipt of a Treatment Plan where the Insured person has declared no conflict(s) of interest, the Insurer must do one of the following:
1. within 10 days of receipt of the Treatment Plan, provide the Insured person with written notice on a form approved by the Superintendent of Insurance, that
  1. describes any conflict of interest that the Insurer has in relation to the Treatment Plan,
  2. describes the goods and services, if any, that are contemplated by the Treatment, and which the Insurer agrees to pay for, and
  3. requiring the Insured person to be assessed under s. 42 in relation to any goods or services which the Insurer does not agree to pay for,
  or
2. within 5 business days of receipt of the Treatment Plan, provide the Insured person with written notice on a form approved by the Superintendent of Insurance, stating that the insurer believes that the Insured person has an impairment to which a Pre-approved Framework Guideline applies, and requiring the Insured person to be examined under s. 42 to assist with the determination as to whether the Insured person should be treated in accordance with a PAF.
If #4 b) applies, please refer to the Rules for Determining Whether an Insured Has an Impairment to Which a Pre-approved Framework Guideline Applies.
The remainder of this particular set of rules pertains only to the notice contemplated in #4 a) above.
Note that under #4 a), there are two possible scenarios. The Insurer may dispute the proposed Treatment Plan, or parts of it because it believes that the proposed treatment is not reasonable or necessary for the injuries sustained in the accident, in which case #5 - 15 below, apply. Or, if appropriate, the Insurer may dispute the proposed Treatment Plan on the basis that the goods and services contemplated by the Treatment Plan are substantially similar to goods and services which the Claimant has previously submitted on a previous Treatment Plan in respect of the same accident, which the Insurer has refused to pay for. In this situation, which by definition can only arise when the Claimant is re-submitting an application for treatment that has been determined not to be reasonable and necessary as a result of a previous s. 42 examination, please refer to the Rules Respecting a Previously Denied Treatment Plan.
If the Insurer is late providing the notice required by #4 a) above, the insurer must pay for all goods and services provided under the Treatment Plan during the period commencing on the 11th business day after the Insurer receives the completed application, and ending on the day the Insurer provides the required notice.
Unless the notice under #4 a) has already provided this information, the Insurer has a 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 (in this case involving the attendance and a personal examination of the Insured)
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 may be given verbally, if written confirmation on a form approved by the Superintendent of Insurance is given as soon as practicable afterwards. The written notice may be delivered by fax to a person or his solicitor or authorized representative, or bypersonal 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 #6 above, cannot be given less than 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 unless the Insured person has sustained a catastrophic impairment, in which case the examination must be completed within 30 days. In other words (unless the Insured has a catastrophic impairment), the examination must be completed between the 5th and 10th day after the notice of the examination, under #6 above, is given to the Insured.
Within 5 business days after the notice of the assessment is given under #6 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 providea copy to the Insured and his or her health practitioner who completed the OCF-18, together with a determination as to which goods and services which were the subject of the s. 42 assessment that the Insured agrees to pay for and which goods and services the Insurer refuses to pay for together with the reasons for the decision.
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 hisor 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 the goods and services contemplated by the Treatment Plan.
If the Insured subsequently complies, the Insurer must reconsider the application based onthe report from the s. 42 examination.
Notwithstanding #12 above, the Insurer is only required to commence paying for the goods and services contemplated by the Treatment Plan, if the Insurer fails to provide the Insured person and his health practitioner with a copy of the report from the s. 42 examination together with its determination of entitlement 15 business days after the s. 42 examination was required to be completed in accordance with #9 above. In other words, the report and determination must be provided not later than 25 business days after the notice of the s. 42 examination is given to the Insured person.Of course, if the determination of the Insurer is that it is not required to pay for the goods and services contemplated by the Treatment Plan, it is only obligated to pay for those goods and services received by the Insured person during the period commencing on the day referred to in the previous paragraph, and ending on the day it does provide a copy of the report and its determination to the Insured person.
If the Insurer determines that the Insured person is not entitled to any of the benefits contemplated by the Treatment Plan he or she can then require the 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 than 40 business days after the Insurer provided the s. 42 report and its denial to the Insured if the Insured has not sustained a catastrophic impairment (in which case this timeframe is extended to 80 business days)
2. the assessment must be conducted by the original provider who approved the OCF-18 unless that original provider is not a member of the same health profession or specialty as the s. 42 assessor
3. if the s. 42 assessor and the original provider who approved the OCF-18 are members of the same health profession, or same specialty if the original provider is authorized to practice in a specialty, the rebuttal assessment is limited to a review of the paper file which was provided to the s. 42 assessor by the parties
4. the rebuttal assessment would also be limited to a review of the paper file which was provided to the s. 42 assessor if the rebuttal assessment is the second one in a 12 month period pertaining to medical and rehabilitation benefits
5. the fee for the rebuttal assessment 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), unless the rebuttal assessment is limited to a paper review, in which case the fee may not be more than $450.

Note that the Insurer is not required to pay a medical or rehabilitation benefit which it has denied 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.