Clients are constantly asking me for the best way to get the insurance company to pay for treatment following an accident.
There are no quick and dirty legal answers to this question, but there are certainly a few routes which need to be explored. While we have a great OHIP system here in Ontario, some forms of treatment simply aren’t covered by OHIP, or they take far too long to get via the public system.
The first question one must ask is whether or not you have private medical benefits offered through your employer, or a private insurance plan. Some people have work coverage for up to $500 in massage, physio, chiro treatment etc offered through their workplace. This would be your first source of recovery for treament funding, regardless of whether or not you’re entitled to accident benefits or not. Under the Insurance Act, the law requires that your first exhaust your private or “collateral benefits”, before you can even touch your accident benefits via Ontario’s complicated No Fault Accident Benefit Regime.
You can often recognize whether or not you’re eligible for collateral benefits by asking your employer, manager, or union rep. One of the quickest ways is checking your wallet for an Employee Benefits Card through a company like Manulife, Great West Life or SunLife, and calling the telephone # on the back of the card, and asking yourself. This is a quick and easy way. This will also help you understand your policy limits, along with what benefits you’re entitled to, or not entitled to. It will also help you better understand how to claim these benefits.
Sometimes, you have to pay for treatment upfront and out of your own pocket; then fill out a form you print out online; then submit to the insurer. Other times, the insurer will pay for the entire treatment upfront. It all depends on your plan and the insurance company.
Once these collateral benefits have been exhausted, the next question we have to ask is whether or not your injury arose from a car accident, or otherwise. If the answer was a car accident in Ontario, then you will be eligible to claim accident benefits under Ontario’s No-Fault Accident Benefits Scheme. More on this later.
If your accident was via slip and fall, dog bite, or some other accident not associated with a car crash, then you will NOT be eligible to claim accident benefits. If you don’t have any form of private insurance, then getting treatment can be difficult, but there are ways.
First, look around your area to find out if there’s an OHIP funded clinic nearby. Many hospitals have OHIP Funded Clinics. Sometimes you will be asked to pay for part of the cost, but that cost is very minimal, and the treatment is better than nothing. Here is a list of OHIP Funded Physio Clinics in Ontario.
You may also want to apply for CPP Disaility, ODSP, or Ontario Works. All are great programs, and can assist you with money for your lodging, rent, medication, treatment, or day to day living.
Determine if you qualify for a private disability plan (Short Term or Long Term Disability). If you’re eligible for benefits, then a large percentage of your pre-accident income might be supplemented which would certainly help pay for treatment.
If you’re paying for treatment out of your own pocket, then it’s really important for you to keep track of where you go, and hold on to your reciepts. Your lawyer will want those reciepts to submit them to the insurer responsible for handling your claim. Your lawyer might be able to assist you in getting the insurer to pay for treatment as you go, before your case settles or goes to trial. From the insurer’s perspective, helping you get better might be the right thing to do. You also might present as less injured at trial which would be helpful for them aswell. From your perpsective, you’re getting treatment so that you can get back on your feet. It’s a win win.
Some providers might agree to treat you and get paid at the end of your case. But be careful when striking a deal with such providers. You might rack up a $10,000 physiotherapy bill in a case only worth $20,000. After you’ve paid your lawyer, your disbursements, and HST, you won’t be left with much money to keep for yourself, let alone pay to the service provider. I’ve seen some cases where service providers just provide treatment blindly in an effort to increase their billings. A $75,000 physio bill after 2 years of treatment is not uncommon. So be careful if you make such a deal.
If your injury arose from a car accident, then the best way to get treatment is via OCF-18 through accident benefits and your own car insurance company. If your treatment provider doesn’t know what an OCF-18 Treatment Plan is, then they ought to read the literature, or you should find a different service provider. Understanding how accident benefit billings works is important for you to understand, and important for your service provider to understand as well. Sometimes proper billing practices on behalf of the clinics are the differnence between your treatment plan getting approved or getting denied.
I trust this information has been helpful for you towards better understand how to get insurers to pay for treatment following an accident. If you have more questions about this, or any other topic, don’t hesitate to contact one of our lawyers at 1-877-730-1777 or at info@goldfingerlaw.com