Attendant Care Benefits
The attendant care benefit may be accessed when an injured person requires assistance with some or all of their personal care activities. The attendant care benefit pays for reasonable and necessary expenses that are incurred by or on behalf of an injured person for services provided by an aide or an attendant or by a long-term care facility such as a nursing home, a home for the aged or a chronic care hospital.
The type of support that an injured person may require following an accident is variable depending on their individual circumstance, but the attendant care benefit is designed to consider all personal care activities and supports. For example, the attendant care benefit may provide assistance with activities including, but not limited to, routine care for dressing, grooming and meal preparation, basic supervisory care, and care for complex activities such as bathing, bowel and bladder programming, ventilator and tracheotomy care, and medication administration and maintenance.
Attendant care benefits may not be accessed by those persons who suffer an impairment that is a minor injury.
Subject to certain payment criteria, the insurer is obliged to compensate the injured person for expenses incurred in obtaining necessary attendant care from an aide or an attendant, regardless of whether the chosen care provider is a non-professional, such as a family member or friend, or a professional, such as a nurse of personal support worker. However, if the chosen care provider is a non-professional, such as a spouse, their entitlement to payment will be restricted to their provable economic losses. In other words, if an injured person’s spouse leaves a job that pays $3,000 a month to provide attendant care to his or her spouse, the attendant care benefit may be limited to $3,000 a month.
It is important to obtain expert advice when trying to understand the options as they relate to the hiring of an aide or attendant and the methods of accessing payment for such care. In this regard, we invite you to contact one of our highly experienced accident benefits specialists for a discussion regarding this benefit.
It should be noted that the insurer may, but is not required to, pay for attendant care expenses incurred prior to the submission of an application for the benefit. Given this restriction, and to ensure that no incurred expenses go unpaid, it is important that an application for the attendant care benefit be submitted as quickly as possible when an injured person requires assistance with personal care activities.
In order to make a claim for attendant care benefits, an injured person must have an Assessment of Attendant Care Needs (Form 1) prepared on their behalf. The Form 1 may be prepared by either an occupational therapist or a registered nurse.
The assessor who is chosen to prepare the Form 1 will meet with the injured person to determine what activities require assistance and also the number of minutes of assistance required for each activity. By completing the Form 1, the assessor is able to calculate the cost of the recommended attendant care on a monthly basis.
Once completed, the Form 1 will be submitted to the insurer, as will the assessor’s fee for the assessment service and form preparation.
Upon receiving the Form 1, the insurer has 10 business days to advise the injured person of the expenses (detailed on the Form 1) that it agrees to pay and any expenses that it refuses. If there is a refusal of a benefit, the insurer must also provide the medical reason and any other justification for its refusal. In the event of a refusal of the attendant care benefit, the insurer may require that the injured person undergo an Insurer’s Examination. If an Insurer’s Examination is required, the insurer must still pay the attendant care benefit, as set out in the Form 1, pending its receipt and release of the Insurer’s Examination Report.
The entitlement to an attendant care benefit will be calculated on the Form 1 and will vary depending on the type of attendant care required by the injured person.
Despite the possibility of a very high amount being calculated on the Form 1, there are also maximum entitlements that may restrict an injured person’s access to the attendant care benefit. In the absence of optional benefits, a person who suffers a non-catastrophic impairment is limited to accessing attendant care benefits at a maximum of $3,000 per month. Of note, this entitlement is paid from the overall combined medical, rehabilitation, and attendant care benefit coverage limit of $65,000 which is only available for the five year period following the accident.
In contrast, a person who suffers a catastrophic impairment may access a maximum attendant care benefit of $6,000 per month. Here too, the entitlement is paid from the combined medical, rehabilitation, and attendant care limit but the limit amount is increased to $1,000,000 and is available over the course of the injured person’s lifetime.
In some cases, attendant care entitlement and the combined coverage limits may be increased if optional benefits were purchased and in effect on the policy of insurance at the date of the accident. Careful review of the policy should be undertaken at the early stages of the claim.
The short answer is yes, but accessing the benefit can be difficult. Whether the attendant care benefit can be accessed for an injured person while in hospital usually depends upon who is providing the care and whether the insurer deems the care to be reasonable and necessary. The insurer will not pay an attendant care benefit if hospital staff members are the only ones who are providing the care.
However, in some cases, whether due to increasing hospital costs, government cutbacks, or other circumstances, some hospital services may be reduced and an injured person may not receive the high level of personal care support necessary to their situation. When family members or friends provide some attendant care to the injured person within the hospital setting, or when private professional support is hired to supplement the hospital staff, it may be possible to access an attendant care benefit.
Cases involving young children who have been injured in accidents often present unique challenges in terms of their personal care needs. Consider the case of a young paraplegic child who is in hospital and requires many daily hours of attendant care assistance. Because of his young age, and his fear, he refuses to have any of the nursing staff at the hospital perform the care. He only allows his mother to perform the required care. As a result, his mother has to take a leave of absence from her employment in order to care for her son full-time while he slowly adjusts to this traumatic experience. In this case, a claim may be made to the insurer for payment of the reasonable and necessary attendant care expenses incurred.
