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MCI Medical Assessments Home Page Why Choose MCI Medical Assessments? Our Services Make a Referral Contact Us Clinic Locations (PDF Map)	Procedure Respecting a Determination as to Whether Proposed Treatment is Similar to a Previously Denied Treatment Plan The rules pertaining to a consideration of proposed treatment that is substantially similar to treatment that has been previously denied by the Insurer are found in sections 38, 42, 42.1 and 68. These rules can be thought of as a subset of the more general rules for determining whether medical and/or rehabilitation benefits are reasonable and necessary. By definition this means that the Insured has previously been to s. 42 examination in respect of the same, or substantially similar treatment, or which the Insurer believes is substantially similar treatment, and rather than submit the dispute to dispute resolution pursuant to sections 280 to 283 of the Insurance Act, has re-submitted the treatment for further consideration on a new OCF-18. The Insured submits an OCF-18 to the Insurer seeking approval for goods and services that are substantially similar to goods or services the insurer previously refused to pay for when they were submitted on a previous Treatment Plan in respect of the same accident. As in the case of any Treatment Plan, there must be disclosure 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, if the Insurer wishes to deny the Treatment Plan (or any part(s) of it on the basis that the treatment contemplated is substantially similar to treatment which it has previously denied in respect of the same accident, the Insurer must 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. Unless the notice under #3 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 to assist the Insurer in determining whether to pay for goods and services which are substantially similar to goods and services which the Insurer has previously refused to pay for 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 #4. 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. 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 Insurer agrees to pay for the goods and services which were the subject of the s. 42 examination, and the reasons for the Insurer's decision. 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 required to commence paying for the goods and services contemplated by the Treatment Plan, 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. 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 that was provided to the s. 42 assessor if the rebuttal assessment is the second one in a 12 month period 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 Respecting a Determination as to Whether Proposed Treatment is Similar to a Previously Denied Treatment Plan

The rules pertaining to a consideration of proposed treatment that is substantially similar to treatment that has been previously denied by the Insurer are found in sections 38, 42, 42.1 and 68.

These rules can be thought of as a subset of the more general rules for determining whether medical and/or rehabilitation benefits are reasonable and necessary. By definition this means that the Insured has previously been to s. 42 examination in respect of the same, or substantially similar treatment, or which the Insurer believes is substantially similar treatment, and rather than submit the dispute to dispute resolution pursuant to sections 280 to 283 of the Insurance Act, has re-submitted the treatment for further consideration on a new OCF-18.

The Insured submits an OCF-18 to the Insurer seeking approval for goods and services that are substantially similar to goods or services the insurer previously refused to pay for when they were submitted on a previous Treatment Plan in respect of the same accident.
As in the case of any Treatment Plan, there must be disclosure 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, if the Insurer wishes to deny the Treatment Plan (or any part(s) of it on the basis that the treatment contemplated is substantially similar to treatment which it has previously denied in respect of the same accident, the Insurer must 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.
Unless the notice under #3 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 to assist the Insurer in determining whether to pay for goods and services which are substantially similar to goods and services which the Insurer has previously refused to pay for 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 #4.
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.
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 Insurer agrees to pay for the goods and services which were the subject of the s. 42 examination, and the reasons for the Insurer's decision.
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 required to commence paying for the goods and services contemplated by the Treatment Plan, 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. 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 that was provided to the s. 42 assessor if the rebuttal assessment is the second one in a 12 month period
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.