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Denied Treatment Plan (OCF-18)? It’s not the end of the world.

After a car accident, an innocent accident victim needs care and treatment to recover from their accident related injuries.

Treatment like physiotherapy, massage, chiropractic care and seeing a psychologist are not free. These items are not covered by OHIP for accident victims. If you want any of this sort of treatment, you will either need to pay out for it out of your own pocket, have an insurer agree to pay for it; or work out some deal with the provider that they provide care now; and that someone (you or an insurer) pays for it later. If the insurer doesn’t agree to pay under this last model, you are the one who will end up paying for it personally.

This is when the OCF-18 Treatment Plan comes in to play. This is essentially a permission slip; whereby the service provider puts forth a plan to provide treatment to an injured accident victim at a set rate. The insurer will either approve (or partially approve) for the treatment. Or they will deny it.

Here is a little bit of knowledge from an experienced personal injury lawyer. Most OCF-18 Treatment Plans get denied at first instance. If this happens to you, don’t take it personally. In fact, it’s quite rare that over the course of a personal injury case, that every OCF-18 treatment plan which gets submitted is approved. We’ve seen it happen. But it’s the exception, and not the norm.

Just because your OCF-18 Treatment Plan gets denied doesn’t mean that it’s the end of the world. That very same treatment plan, may get approved in the near future. Or perhaps, with a bit of convincing, the insurer may come to their senses and approve it.

Sometimes insures just want more information. That more information may come in the form of additional, or updated medical records.

That more information may also come in the form of an insurance examination, or IE as they are known. These IEs are dreaded and feared examinations. Rightfully so. They take place with a doctor, or a rehabilitation professional who is hand picked and paid by the insurance company to assess the accident victim and to determine whether or not the proposed treatment plan is both reasonable and necessary. The IE assessors bill the insurance company directly. For a great article on some of the insight on the Insurance Examination Industry, check out this investigation piece by the Globe and Mail “License To Bill: How Doctors Profit from Injury Assessments that Benefit Insurers“.

It would be an interesting study, but I fare to guess that the vast majority of IE reports which return likely go in favour of the insurer, and not the injured accident victim.

But don’t give up hope.linkedin-2-300x300

Sometimes, IE reports come back in support of the injured accident victim. When the IE report comes back that way, the insurer will approve the OCF-18 Treatment Plan. That’s great news for the applicant because they will be getting the treatment which they need to get better.

If the IE report comes back denying treatment; all is still not lost.

For starters, the injured accident victim can submit another treatment plan, for a different service provider in a different field. The result of the IE may have returned noting that physiotherapy was not recommended, but massage would be considered. In that case, get a new OCF-18 Treatment Plan from a massage therapist and withdraw the OCF-18 Treatment Plan for physiotherapy.

In other cases, the injured accident victim may wish to apply to the License Appeals Tribunal (LAT) to have an Adjudicator decide on the issue. The Adjudicator will act as a Judge, and determine based on the evidence before him/her whether or not the OCF-18 Treatment Plan is reasonable and necessary. It’s like conducting a full blow trial on whether or not the Applicant is entitled to treatment. It’s interesting to note that these are treated much like trials. They are called hearings and can last multiple days. What ends up happening is that both the insurer and your personal injury lawyer spend a disproportionate large amount of time and money on the hearing when examining the value of the benefit in dispute. The lawyers will spend $20,000+ worth of time/money on an $5,000-$10,000 issue.

This is insignificant for the insurance company as they have seemingly unlimited (or much more) resources than you to spend fighting these issues. And unlike at a civil trial, there are no legal costs which are awarded at the LAT. There are special awards which can be awarded in exceptional circumstances to compensate a party for another party’s bad behaviour. But these special awards are rather low ($500-$750 or so).

Regardless, there is a place for the accident victim to get justice. Unfortunately, the LAT is a very rigid and inflexible forum. We’ve seen cases where both the insurer and the applicant have consented to an adjournment in order to save time, money and costs so that they could work things out with a private mediator. Despite the consent adjournment request, the officers at the LAT declined the wishes of the parties and rejected the joint application. In our experience, most cases decided at the LAT have gone in favour of the insurer and not the other way around. So, tread on this forum delicately as there are a lot of pitfalls in using it.

It’s important for accident victims to keep in mind that insurers aren’t in the business of gratuitously paying out money; even if that money is for treatment. The more money which they pay out on claims, the less money they get to hold on to and report in profits, or use for investments to generate more money. When a claim for treatment is denied, it’s very personal for the accident victim. But for the insurer, it’s part of their business model. To believe that an insurer will pay out on each and every claim for treatment submitted to them is not to face the reality of what personal injury and accident benefit claims are all about. Insurers would rather pass the treatment bill along to another insurer, or to the publicly funded OHIP system where they can in order to support their bottom line.

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