Ontario insurer not obliged to pay for assessments that it did not pre-approve: FSCO

An Ontario woman who unilaterally sought Cdn$18,073 worth of medical assessments is not entitled to recoup the money from her insurer, since she did not obtain her insurer’s approval in advance of the assessments, the Financial Services Commission of Ontario (FSCO) has ruled in an arbitration.
Kathryn Scott was injured in a motor vehicle accident in September 2002. She applied for and received statutory accident benefits from Dominion of Canada General Insurance.
Scott applied to Dominion in December 2004 for a first determination of whether she has suffered from a catastrophic impairment.
The company responded in February 2005 that it did not feel she was catastrophically impaired and that they wished to have her assessed at a DAC centre.
The DAC centre assessment found that Scott was not catastrophically impaired.
Scott subsequently underwent a series of assessments conducted by CEMED Inc. in January 2007. The arbitrator found Scott did not tell Dominion about her plans to undergo the CEMED assessments, nor did she complete or submit to Dominion an OCF-22 form (an application for approval of an assessment or examination).
The CEMED assessments found she did indeed have a catastrophic impairment. Scott then reapplied to Dominion for a second determination of whether she was catastrophically impaired. The insurer had her re-assessed at LifeMark Assessments, the result of which was inconclusive.
After further review, Dominion later found Scott to have been catastrophically impaired.
Scott attempted to recoup the money for the CEMED assessment, arguing that s. 24(1) of the SABS says an insurer shall pay for “reasonable fees charged by a health practitioner for preparing an application under section 40 for a determination of whether the insured person has sustained a catastrophic impairment.”
But the arbitrator noted that s. 24(1) has important qualifications. In s. 24(11), for example, the insurer’s pre-approval of the treatment plan is required for 24(1) to apply.
Since Scott had not submitted an OCF-22 to Dominion, nor was it clear whether or not she had ever really told Dominion of her plan to be assessed by CEMED, Dominion was not obligated to pay for her CEMED assessments, the arbitrator ruled.