Cost Of Catastrophic Impairment Assessment Paid Outside Of Person’s Medical And Rehab Limits – RB v. RSA

April 02, 2020, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

Cost Of Catastrophic Impairment Assessment Paid Outside Of  Person’s Medical And Rehab Limits – RB v. RSA

Date of Decision: March 6, 2020
Heard Before: Tavlin Kaur

ASSESSMENTS: who pays the cost of the CAT assessment; does the cost come from the medical and rehab benefits; is the cost of the CAT assessment paid outside the limits; cost is paid outside limits; CAT designation is not a benefit it is a designation

RB was involved in a car accident in April 2017 and sougth benefits pursuant to the SABs. He was denied certain benefits and cost of examinations by RSA and applied to the LAT.

Issues:

1. Is RB entitled to payments for the cost of examinations in the amount of $16,272.00 for catastrophic assessments?
2. Is RB entitled to a medical benefit in the amount of $1,795.50 for physiotherapy treatment?
3. Is RB entitled to a medical benefit in the amount of $205.40 for medication?
4. Is RB entitled to a medical benefit in the amount of $1,901.88?
5. Is RB entitled to an award under Ontario Regulation 664 because the respondent unreasonably withheld or delayed the payment of benefits?
6. Is RB entitled to interest on any overdue payment of benefits?

Results:

1. RB is entitled to the cost of examinations.
2. RB is not entitled to the claimed physiotherapy and prescription plans in dispute.
3. RB is not entitled to an award.

Reasoning:

Adjudicator Kaur reviewed the facts of the case and the law.

RB submitted a plan for CAT assessment in the amount of $16, 272 which RSA denied. He submits that CAT assessments are not subject to the medical and rehab benefits in section 18(50 of the Schedule.

RSA took the position that since RB had exhausted the monetary limit set out in section 18930 of the Schedule under the policy for non-catastrophic injuries the treatment plan is not payable. Adjudicator Kaur agreed with RB noting:

• catastrophic assessments are not subject to the medical and rehabilitation limits set out in section 18(3)(a) of the Schedule.

Section 18(3)(a) of the Schedule addresses the monetary limits for medical and rehabilitation benefits. This section states that:

The sum of the medical, rehabilitation and attendant care benefits paid in respect of an insured person who is not subject to the financial limit in subsection (1) shall not exceed, for any one accident, $65,000; or if the insured person sustained a catastrophic impairment as a result of the accident, $1,000,000.

Section 18(5) of the Schedule states that:

For the purposes of subsections (1) and (3), medical, rehabilitation and, where applicable, attendant care benefits payable in respect of an insured person include all fees and expenses for conducting assessments and examinations and preparing reports in connection with any benefit or payment to or for an insured person under this Regulation, other than,

               (a)     fees in connection with any examination required by an insurer under section 44; and

               (b)     expenses in respect of a report referred to in subsection 7(4). [Emphasis added]

The wording in this section specifically states that it must be in connection with any benefit or payment. In my view, the catastrophic designation is not a benefit.  Rather, it is a designation that gives the applicant access to a higher monetary limit should it be determined that the applicant has sustained a catastrophic impairment as defined in the Schedule. 

The applicant is relying on section 25(1)5 of the Schedule. This section states that the insurer shall pay the following expenses incurred by or on behalf of an insured person:

Reasonable fees charged for preparing an application under section 45 for a determination of whether the insured person has sustained a catastrophic impairment, including any assessment or examination necessary for that purpose. [Emphasis added]”

Following the premise that every word in a statute has been included for a reason and purpose, the fact that “shall pay” provision in Sc21(105 of the Schedule for catastrophic assessments leads the Adjudicator to believe that it was not the legislature’s intent to caprue these assessments within the confines of sec 18(5) of the Schedule. In the Adjudicator’s opinion there is no ambiguity and it is quite clear the CAT assessments are covered by sec 25(1)5 and the applicant is entitled to payments of $16, 272.00 for the CAT assessments.

About Deutschmann Law

Deutschmann Law serves South-Western Ontario with offices in Kitchener-Waterloo, Cambridge, Woodstock, Brantford, Stratford and Ayr. The law practice of Robert Deutschmann focuses almost exclusively in personal injury and disability insurance matters. For more information, please visit www.deutschmannlaw.com or call us at 1-519-742-7774.

The opinions expressed here, while intended to provide useful information, should not be interpreted as legal recommendations or advice.