At the hearing, State Farm argued that the disputed treatment plans were invalid because they had not been signed by the claimant and her health practitioner, as required by subsection 38(3) of the Statutory Accident Benefits Schedule (O. Reg. 34/10):
State Farm argued that the disputed treatment plans were invalid because they had not been signed by the claimant and her health practitioner... |
(3) A treatment and assessment plan must,
(a) be signed by the insured person unless the insurer waives that requirement;
(b) be completed and signed by a regulated health professional
The failure of the claimant to sign the treatment plan meant subsection 38(2) relieved State Farm of the responsibility to pay for them:
(2) An insurer is not liable to pay an expense in respect of a medical or rehabilitation benefit or an assessment or examination that was incurred before the insured person submits a treatment and assessment plan that satisfies the requirements of subsection (3)
Arbitrator Sapin concluded that the language of section 38 is "clear and straightforward". She held that this language confirms that an insurer is under no obligation to pay for the services described in a treatment plan that was not signed by the claimant and her health practitioner.
In light of Chaparina, I recommend accident benefits insurers never waive the requirement to have the claimant sign the treatment plan (which insurers are allowed to do pursuant to paragraph 38(3)(a)), absent exceptional circumstances that are well-documented by the adjuster handling the file. The requirement that both the claimant and the health practitioner sign the treatment plan helps prevent fraud and ensures that both the claimant and health practitioner agree that the requested treatment is needed (indeed, Ms. Chaparina admitted at the arbitration that she had not known about the treatment plans and did not receive the proposed services).
(The Arbitrator's) words suggest that State Farm may have an obligation to inform the claimant of the importance of signing treatment plans. |
Arbitrator Sapin mentioned in passing that it would have been better if State Farm raised the issue of the unsigned treatment plan before the hearing. Her words suggest that State Farm may have an obligation to inform the claimant of the importance of signing treatment plans. This obligation is consistent with the general responsibility of an accident benefits insurer to ensure that claimants understand how to claim benefits.
Those of us who work in the field of accident benefits know that treatment plans that are submitted via the Health Claims for Auto Insurance service are not signed. That does not relieve the claimant and the health practitioner of their obligation to sign the document. It is a good idea for the accident benefits insurer to request the clinical notes and records of the facility that submitted the disputed treatment plans. Those clinical notes should contain a copy signed by both the claimant and the health practitioner. A lack of signed copies should raise eyebrows and may prove decisive at a later arbitration.
1 FSCO A14-007595, decision dated February 19, 2016.
2 A recent commented on the impact of her rulings "The requirement to provide "medical reasons" when denying treatment plans: a ticking time bomb?"
