Submitting Medical Cannabis Expenses: Dealing with Forms and Reluctant Insurers
Cannabis has become one of the most effective and popular medications for those suffering from chronic pain, depression and anxiety.
Unfortunately, Cannabis, at least for many over 35, is still thought of as a recreational drug that is more suited to enjoying a concert than treating a medical condition. The science seems clear – it does work. It helps people with a range of medical conditions and has few side effects along with absolutely no danger of overdose.
Many people who run insurance companies simply do not view this as real medication. They still think of it as a drug that they smoked in high school. They do not want to pay for it.
Insurers are finding that it is getting harder and harder to deny that the drug works. They used to be able to easily find doctors that would write a report saying the medication was not appropriate or would not work. They would base their denial on the misguided position that the drug was not an effective treatment, or at the very least, was novel and unproven.
Insurers are moving away from this position but still do not want to pay for what they consider to be “pot”. Insurers have found a different tactic – they insist that a Treatment and Assessment Plan (OCF18) is required before they have to pay for Cannabis. While it does not prevent the payment, it does seem to delay it.
This poses many problems for our clients. First, they may have to wait months before being reimbursed for a relatively expensive drug. Second, the cost of the treatment plan will take a chunk out of their medical and rehabilitation benefits, which for some are not much to begin with. This ends up preventing them from getting treatment they need.
The insurer’s approach is completely at odds with the Treatment and Assessment Plan form. The form clearly states that the form is not to be used to make a claim for “drugs prescribed by a regulated health professional”.
The Licence Appeal Tribunal has dealt with this issue. In 17-001866 v Aviva Insurance, the adjudicator touched on the issue of whether a treatment plan was required for Cannabis. In this case, the insurer required a treatment plan. The applicant submitted the Cannabis expense using an Expense Claim Form. The adjudicator stated that, when prescribed by a regulated health professional, a treatment plan is not required for Cannabis.
Despite the law being clear, we are still seeing insurers insist that requests for Cannabis be made with a treatment plan. It is important that we work together to put pressure on the insurers to make sure our mutual clients get the medication they need in a timely matter. Sometimes this can be accomplished by simply reminding the insurer of the law. We have had a measure of success pointing out the law and insisting that the insurer pay the expense. Sometimes in these circumstances, diplomacy is the best course to make sure the client gets the medication in short order.
If the insurer still insists on a treatment plan, we must work together to decide the best course of action. The question is, is it faster for us to file the treatment plan or fight the insurer on this issue? While we are reasonably certain we could prevail at the Licence Appeal Tribunal on this issue, this would involve substantial delay for the client. That delay could result in the client living without needed medication for many months while we litigate the matter. That of course does nothing for the client. If we can get the medication to the client sooner by simply filing a treatment plan, that, in many cases, may be the best way to proceed.
Our goal is not to beat the insurance company on this issue, but rather, get the client the help they need as soon as possible.
About the Authors
Brian Cameron joined Oatley Vigmond in 1999 after obtaining his law degree from Western University. Beginning his journey in an articling position, fresh out of law school, the first case he argued in court was a small claim’s trial for the firm’s then-senior partner, who was suing a dry cleaner who’d lost three of his dress shirts. Brian won that action for $285 plus costs, and has been with the OV team ever since. He became a partner in 2008.
Merella is committed to advocating on behalf of people who have suffered serious personal injuries. She understands that the complexity of the insurance system can be intimidating for clients, and wants to make the process as easy as possible for them. Merella first joined Oatley Vigmond as an articling student in 2017, becoming an associate after being called to the bar in 2018. Merella obtained her law degree from the University of Windsor and an Honours B.A. in Philosophy and Criminology from York University. In her spare time, Merella enjoys exercising, travelling, and reading. Merella is fluent in Arabic.