V702 – Once Again – The Costs of Catastrophic Assessment – Confirmed as Not Part of Medical and Rehabilitation Coverage Limits

Surprisingly, another insurer has taken another swing at trying to suggest that the costs of catastrophic assessments ought to be paid as a medical and rehabilitation benefit.

There have now been several decisions written with regards to this issue. Time and again, decisions have confirmed that catastrophic assessments are a procedure used to access the next tier of benefits and that the medical and rehabilitation coverage limit, as set out in section 18 of the SABS, is therefore not applicable to their related cost. Indeed, we highlighted this point in our June 1, 2018 publication which reviewed past decisions and highlighted the LAT’s decision on 17-003496, Applicant and TD Insurance.

This brings us to 17-007962, N.S. and Scottish & York. This hearing done in writing was held on May 14, 2018 and the adjudicator quickly released his related decision dated on May 25, 2018.

In brief, the insurer had approved catastrophic assessment costs, as requested by way of treatment and assessment plan in the amount of $18,534, but noted intention to deduct the costs from the medical and rehabilitation coverage limit. Because the limit of $50,000 had already been exhausted, the insurer subsequently refused to fund payment of the otherwise approved assessment. The insurer maintained its position despite the applicant’s pleas and a hearing at the LAT proceeded.

In rendering his decision, a decision which confirmed that the insurer cannot deduct catastrophic assessment costs from the medical and rehabilitation coverage limit, Adjudicator Christopher A. Ferguson stated:

“The effect of deducting CAT assessment costs from the $50K available to “not-yet-CAT” consumers would be to force seriously injured people to plan to hold a significant percentage of entitlement – in this case 37% — in reserve, just in case they need a CAT assessment. This would represent a serious deterrent to seeking needed treatment, or alternatively act as a major barrier to seeking CAT determination. I find it simply unbelievable that such obvious effects are intended or supported by any reasonable interpretation of the Schedule.”

We can only hope that insurers have heard the message that catastrophic assessments are not to be paid from the coverage limits. Perhaps this present case will be the final decision published in relation to such a dispute.

Official Decision:

17-007962, N.S. and Scottish & York

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