The road to recovery can be a long one following a serious accident. You’ll need all the help you can get; and sometimes the help provided through the publicly funded OHIP system just isn’t enough.
Treatment like physiotherapy, occupational therapy, massage, psychological counselling, speech language pathology and chiropractic treatment in the majority of cases aren’t covered by the OHIP system.
Sometimes insurers will pay for this sort of treatment while the case is still open; in order to support your wellness and rehabilitation.
In car accident cases, these treatments can be paid for by way of an accident benefit claim via OCF-18 Treatment Plan. The car insurer will only pay for the treatment provided that they deem the treatment to be both “reasonable and necessary“. Unfortunately, the insurer gets to act as Judge, Jury and Executioner in deeming whether or not the proposed treatment via OCF-18 Treatment Plan is “reasonable and necessary“; which can be very frustrating for clients.
We agree with our clients that getting medical treatment following a serious accident is very important and crucial to recovery. This cannot be understated.
But what happens when the insurer won’t pay for treatment? What can you do about it? Who will pay?
You can pay out of pocket, but that’s not an option for everyone.
If the client isn’t rich, and can’t afford to pay for treatment out of pocket, then what happens?
Some clients opt for a litigation loan through a third party lender in order to help make ends meet. But this is only a temporary solution and essentially creates a lien on the client’s file which is subject to high interest rates, set up fees, annual renewal fees, file closing fees, etc. Before you know it, that $3,000 litigation loan has ballooned to $7,500 and rising every day.
Some clients work out arrangements with their service providers such that the service provider will agree to provide treatment, and only charge for that treatment once the case settles.
Be careful if you enter in to one of these protected account agreements with your service provider. It’s akin to going to the bar and setting up a tab. By the end of the night, you really don’t know how much you’ve had to drink, how much each drink cost, and what other charges have been tacked on to the bill. When you finally get the bill at the end of the night, it’s always an unpleasant surprise.
Setting up a protected account arrangement with your service provider is no different. The service provider whether it’s a physiotherapist, chiropractor, masseuse, or therapist will gladly see you every day for treatment. They know that the more you come in for treatment, the more they get to bill at the end. The more they get to bill, the more they will get paid at the end.
At the end of the day, the client will be left with significant less than they would expect.
Take the following example. You’ve sustained an injury in a car accident. The accident benefit insurer pays for the first few chiropractic treatment plans which were approved via OCF-18 Treatment Plan. But the third treatment plan submitted by your chiropractor gets denied.
Your chiropractor agrees to treat you without charging you upfront, provided you sign an Irrevocable Direction which protects his account such that you promise to may him upon settlement of your case. This Irrevocable Direction is also sent to your personal injury lawyer.
Your chiropractor gladly treats you 2-3 days per week, over a two year period. You have no idea how much he is charging you per session, and no idea what amount will be owing to him when the case settles. When you inquire as to the chiropractor how much will be owing to him, he simply tells you “don’t worry about it“.
The case eventually settles for $100,000. Your lawyer is charging you 25% for legal fees ($25,000), plus HST ($3,250), plus disbursements ($6,000). You also have to pay back a litigation loan of $6,000. This should leave you with $59,750.
When you inquire as to your chiropractor how much is owing, you see a bill of $15,000, plus interest which takes the total to $17,500!
After paying the chiropractor, you’re left with just $42,250, which is under HALF of the value of your $100,000 settlement! How did the client end up with so little, while everyone else ended up with seemingly so much?!?!?!
While this is a rather extreme example, our lawyers can tell you that’s it’s not uncommon. We see a lot of these situations around the Greater Toronto Area.
You can prevent it from happening in a wide variety of ways. For starters, don’t enter in to the protected account/irrevocable direction agreements. You never know how much will be owed to the service provider at the end of the day.
Look in to getting on a wait list for OHIP Funded services such as OHIP Funded Physiotherapy clinics. You can find a list of publicly funded physiotherapy clinics here.
If you must enter in to one of these agreements, get a monthly, if not a weekly statement to make sure that the service bill doesn’t get out of control. Discuss with your family doctor whether or not the proposed services, along with the frequency of those services is a good idea. Figure out what works best for you, and don’t just go to the clinic for treatment for the sake of getting treatment if the treatment isn’t useful or beneficial towards your wellness and rehabilitation. Only you and your family doctor can judge this.
Ask your personal injury lawyer and family doctor if the proposed course of action is a good one, and whether or not there will be a reasonable prospect for recovery should you continue that course of treatment. In some cases, there may be no legal chance of ever recovering enough compensation to make you financially whole; along with all of the other service providers you are seeking to pay out from your personal injury settlement.
Ask the service provider if s/he is charging you any interest (if so, then how much), or any other hidden fees. Find out how much each session will cost, and ask why each session is necessary towards your well being. Getting treatment for the sake of a third party service provider to rack up his/her bills and accounts receivable isn’t a good recipe for any personal injury case.