Insurance statutes and policies provide for the resolution of claims in a multitude of ways, thus necessitating the need for insurers to identify the relationship between claims with a view to the efficient and effective resolution thereof. This article discusses the upcoming introduction of yet another means by which insurance claims may be satisfied, being regulations providing for the diagnosis and treatment of minor injuries under Section B of claimants’ policies.
On June 25, 2024, the Honourable Sarah Stoodley, Minister of Digital Government and Service NL, announced new diagnostic and treatment protocols under Newfoundland and Labrador’s Automobile Insurance Act, RSNL 1990, c. A-22. In a media release, Minister Stoodley explained that:
“New diagnostic and treatment protocols under the Automobile Insurance Act will allow accident victims to get quicker and more affordable treatment, specific to the most common types of injuries resulting from an automobile accident: sprains, strains and whiplash associated disorders.”
Although not addressed in the Automobile Accident Diagnostic and Treatment Protocols Regulations, NLR 36/24 (the “Regulations”), Minister Stoodley’s press release states that
“Health care practitioners who choose to provide services under the new protocols will bill the insurance company directly for their services. This will eliminate the need for the accident victim to pay up front and wait for reimbursement from the insurance company.”
The Regulations were published in the June 21, 2024 edition of the Newfoundland and Labrador Gazette and will come into force on December 2, 2024. They comprise 36 sections which provide only for injuries arising from automobile accidents.
The Regulations provide claimants with the autonomy to decide whether they would prefer: (1) to be treated pursuant to the terms of the Regulations; or (2) to access Section B benefits by filling out a claim form and awaiting their insurer’s approval.
The caveat here is that treatment under the Regulations does not require the insurer’s consent but is limited in duration and does not contemplate certain Section B coverages which would be beneficial in more serious accidents, such as weekly indemnity for loss of income.
The Regulations apply only to whiplash, sprain and strain injuries which arise from motor vehicle accidents. Where an injured person suffers from one of these ailments, they may seek treatment in accordance with the Regulations without the need for advance consent from their insurer. Such treatments, however, must be performed by a healthcare practitioner who has consented to acting in accordance with the Regulations and the payment scheme set out therein. The Regulations apply only on the earlier of 90 days following the injury or when the maximum number of visits is exhausted.
The maximum number of visits is established by sections 20 and 21 of the Regulations, which allows 10 visits for less serious and 21 visits for more serious injuries. That said, an injured person or their health care practitioner can apply under section 7 of the Regulations to the insurer “… for approval for a service or supply in addition to the limits specified [therein].”
The Regulations provide for the diagnosis and treatment of specific injuries and include tables in accordance with which treatment providers are to diagnose injuries. Furthermore, the Regulations set out exactly how such injuries are to be treated, placing specific emphasis on providing only treatment that is medically necessary/justifiable, discouraging patients from “depending on health care providers and passive modalities of care for extended periods of time,” and educating patients on the benefits of returning to normal daily activities/encouraging same.
As one would expect, with new legislation comes a new regime with which insurers must comply.
Following receipt of a bill charged under the Regulations, insurers will have 5 days to notify the patient – in writing – of whether they accept or deny the claim. There are limited circumstances in which a claim may be denied which include, inter alia, where the injuries were not sustained in an automobile accident or where the patient is not an “insured” under the policy. Where a claim is accepted, an insurer has 30 days to submit payment therefor pursuant to section 33(2).
Should an insurer miss the 5-day period by which to respond to the patient, they will be deemed to have accepted the claim and will thus be liable to pay same. That said, insurers may retroactively deny a claim in accordance with section 32, which provides that claims may only be denied where (a) the person who suffered the injury is not an insured person under a contract that provides accident benefits; (b) the insurer is not liable to pay as a result of an exclusion contained in the Special Provisions, Definitions and Exclusions of a contract that provides accident benefits; (c) there is no contract of insurance in existence that applies with respect to the person who suffered the injury; or (d) the injury was not caused by an accident arising out of the use or operation of an automobile. Where an insurer retroactively denies a claim, they must send notice – in writing – containing the reasons for the denial to the patient and every health care provider to whom the patient is authorized to visit under the claim form.
The Automobile Accident Diagnostic and Treatment Protocols Regulations were created for the purpose of ensuring the timely and financially non-burdensome recovery of accident victims by allowing health care providers to direct-bill insurance companies without the need for advance claim acceptance. This change was characterized by Minister Stoodley as follows:
“The new protocols mean that individuals injured in an auto accident can get faster treatment and may have a faster recovery. Win, win.”
It remains to be seen whether the implementation of these Regulations will have the desired effect on accident victims.
Prove-it! The British Columbia Court of Appeal Confirms the Tripartite Test for Future Loss of Earning Capacity Claims Must Be Met in Full
read moreBackground After suffering injuries in a motor vehicle accident, the plaintiff was placed off work and provided with loss of income benefits under Section B of her policy through Aviva. The plaintiff received these benefits for 104 weeks. She was subsequently cleared to return to work and did so for the following 13 months, before […]
read moreOn Friday, December 1st, 2022, a panel of Cox & Palmer insurance lawyers from across the region presented our Case Law Update: Recent Key Decisions in the Atlantic Provinces Webinar, which covered current developments and recent key decisions in the region, from the last couple of years. Access Paper Here
read more
