Mileage Expenses Not Paid for Unapproved Treatment Plans

March 12, 2017, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer

J.H. v Intact – Payment of mileage expenses; transportation only required to be paid to insured for approved treatment plans; SABs rules clear

J.H. v Intact Insurance Company, 16-000009

Date:    2016-09-08
Heard Before: Adjudicator Cynthia Pay

DECISION

Issue:

1. Is Intact required to pay for mileage expenses for J.H.’s service providers in the treatment plans under dispute under the SAB?

Decision:

1. Intact is not required to pay for the mileage expenses of J.H.’s service providers in the treatment plans in dispute.

J. H. was hurt in a car accident on February 14, 2012 and sought benefits pursuant to the Schedule.  The parties confirm in their Agreed Statement of Fact that J.H. sustained a catastrophic impairment in this accident. J.H. submitted an application for dispute resolution services to the Tribunal regarding the denial of mileage expenses claimed by health care providers for travel to and from J.H.’s home.

At the case conference and in their Agreed Statement of Fact the parties agreed on the amounts and treatment plans in dispute, along with interest on any overdue benefits. The parties agree that Intact paid for the time for travel of the service provider proposed on each treatment plan at the maximum hourly rate for professional services pursuant to the Professional Services Guideline.

The parties agree that the issue in dispute is a purely legal one, as it relates to the interpretation of the Schedule with respect to mileage claims by treatment providers, and consented to a written hearing of this issue.

The Arbitrator reviewed the law and the case before her.

J.H. takes the position that his service providers should be entitled to mileage costs under the SAB.  He was deemed to be catastrophically impaired because of his motor vehicle accident.  He asserts that services are best provided to him in his home and community, and that his service providers have to travel from surrounding areas to provide this treatment because he lives in an area where access to treatment is limited.  J.H. submits that mileage costs are therefore a reasonable and necessary part of his treatment requirements.

Intact disagrees that they are required to pay for mileage costs under the Schedule.  They submit that there is no evidence before the Tribunal regarding J.H.’s need for treatment in the home or whether J.H. lives in an underserviced area.  They further submit that the Schedule and related Professional Services and Transportation Expense Guidelines do not require insurers to pay for the mileage costs of service providers.

Sections 15 to 17 of the Schedule outline when medical benefits, rehabilitation benefits, and case management services must be paid.  The Schedule provides for services including occupational therapy and case manager services, “as well as transportation for the insured person to and from treatment sessions, including transportation for an aide or attendant”. Section 15(2) outlines that Intact “is not liable to pay medical benefits…(c) for transportation expenses other than authorized transportation expenses.”\

FSCO directed that in these cases The Professional Services Guidelines be consulted which state that “automobile insurers are not liable to pay for expenses related to professional services rendered to an insured person that exceed the maximum hourly rates set out in the Appendix”.

FSCO is aware that some health care providers are submitting mileage expenses to insurers to travel to an injured accident victim’s location when providing services.  Insurers are reminded that "authorized transportation expenses", as defined in the SABS, are intended to apply to expenses incurred by the insured person and an aide for travel to and from treatment sessions, subject to the Superintendent’s Transportation Expense Guideline.

Insurers are also reminded that the Superintendent's Professional Services Guideline states that:

"Expenses related to professional services" as referred to in the SABS and the Professional Services Guideline include all administration costs, overhead, and related costs, fees, expenses, charges and surcharges. Insurers are not liable for any administration or other costs, overhead, fees, expenses, charges or surcharges that have the result of increasing the effective hourly rates, or the maximum fees payable for completing forms, beyond what is permitted under the Professional Services Guideline. Both guidelines are incorporated by reference into the SABS.

On this basis, the Arbitrator found that Intact is not required to pay for the mileage costs for J.H.’s treatment providers under the SAB.

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