10/11/2017 0 Comments
ICBC Medical and Rehabilitation Benefits
Most people injured in a motor vehicle accident in British Columbia are entitled to medical and rehabilitation benefits from the Insurance Company of British Columbia (ICBC). These benefits are paid regardless of who was at fault for the accident. Entitlement to these benefits is set out in Part 7 of the Insurance (Vehicle) Regulation.
To qualify, a claimant must promptly notify ICBC of the accident. Make a claim within 90 days of the accident.
If a claimant has insurance with any private or extended group benefit program, those benefits must be used first.
There are two types of medical and rehabilitation benefits available from ICBC - mandatory and permissive.
As the name suggests, mandatory benefits must be paid by ICBC. These include all reasonable expenses resulting from the injury for necessary medical, surgical, dental, hospital, ambulance or professional nursing services, or for necessary physical therapy, chiropractic treatment, occupational or speech therapy, or for prosthesis or orthosis. Mandatory benefits include travel expenses necessary to access these treatments.
It is for the claimant’s own medical team to decide on the appropriate treatment. At times, disputes may arise with ICBC as to what is “reasonable”. As discussed below, there is an arbitration process for resolving these disputes.
Services for certain mandatory benefits may be provided by various treatment modalities. For example, physical therapy treatment may be provided by a registered massage therapist instead of a registered physical therapist if recommended by a doctor. Mandatory benefits for physical therapy are limited to twelve sessions unless there is written confirmation from a medical practitioner that more treatment is necessary.
Permissive benefits may be provided to a claimant where, in the opinion of ICBC’s medical advisor(s), the benefit is likely to promote rehabilitation of the claimant. The claimant must obtain written approval from ICBC before incurring any expense for a permissive benefit. Before approving a permissive benefit, ICBC may require the claimant to submit additional information.
Certain permissive benefits are available only on a one-time basis. These include the purchase of a specially equipped motor vehicle or alterations to the claimant’s residence to make it accessible.
Other permissive benefits may be available on a monthly or time-to-time basis. These include attendant care costs, other than care provided by a family member, where the claimant is residing in the community but is unable to live independently. Other benefits include a wheelchair, medically prescribed bed, bowel and bladder equipment, aids for communication, dressing, eating, grooming and hygiene, transfer equipment or a ventilator. Vocational training may also be available. Expenses for attendant care and pain management treatment that allow the claimant to carry out activities of daily living or cope with pain, but do not promote rehabilitation in the sense of restoring function, are not covered.
ICBC has discretion with respect to permissive benefits, but that discretion is not absolute or unfettered. The decision must be based on criteria that are specifically described or determinable. The decision must also be rationally connected to relevant factors governing an objective assessment of the entitlement to benefits.
ICBC’s Internal Policies
ICBC has internal policies that may restrict coverage. For example, the number of massage physiotherapy treatemnts are limited an initial 20 visits. In addition, the amount paid for certain treatments such as massage therapy and chiropractic treatment is limited. These policies do not have the force of law and ICBC adjusters have the discretion to depart from them.
ICBC may require a claimant to provide a medical certificate or report as to the nature and prognosis of the claimant’s injuries. ICBC also has the right to require that a claimant be examined by a doctor of ICBC’s choice as a condition of paying benefits. This is known as an independent medical examination (IME).
The total coverage available for medical and rehabilitation benefits is $150,000 per claimant injured in the accident. A claimant can only recover expenses incurred beyond the limit through a personal injury lawsuit.
Disputes Over Expenses Covered
If a dispute arises as to whether an expense is reasonable, ICBC must submit the matter to arbitration under the Arbitration Act. For arbitration to occur, there must be a claim submitted for reimbursement of an expense, denial by ICBC on the basis that the expense is unreasonable, communication to the claimant of that denial and a dispute by the claimant as to ICBC’s decision.
Where all of these requirements are met but ICBC does not, within a reasonable time, take steps to begin arbitration, ICBC’s right to have the matter determined by arbitration is considered to have been waived. In those circumstances, the court has jurisdiction to decide the matter.
Legal Assistance for Securing Benefits
If you are having difficulty accessing coverage for medical and rehabilitation benefits, legal advice is recommended. Our car accident lawyers at Bronson Jones & Company LLP deal regularly with ICBC as we exclusively represent victims who have been injured in motor vehicle accidents. We have 13 offices in the Lower Mainland, serving Abbotsford, Burnaby, Chilliwack, Coquitlam, Langley, New Westminster, Port Coquitlam, Surrey and Vancouver.