The cost of Physiotherapy is NOT covered by OHIP. That means that if you need physiotherapy, someone needs to pay for it.
The cost of chiropractic treatment is NOT covered by OHIP. That means that if you need chiropractic treatment, someone needs to pay for it.
The cost of out of hospital occupational therapy is NOT covered by OHIP. That means if you need to see an occupational therapist, someone needs to pay for it.
The same applies to psychotherapy, massage, cranial sacral treatment, nutritionist, a rehab coach, a PSW, an RSW, social work for a car accident case outside of hospital, speech language therapy, neuropsychological testing, driver retraining, case management services, psychology (not to be confused with psychiatry); even some forms of medicinal cannabis for pain management are not covered by OHIP.
All of these services are very important to accident victims for the long roads to recovery following a accident; motor vehicle or otherwise.
If the accident victim has their own form of collateral benefits with an insurer like Blue Cross, Manulife, SunLife, GreenShield, Canada Life etc.; some or percentage of those benefits may be covered. Most policies differ; but it’s not uncommon to see a cap for these services set at around $500 or $750 per year.
If the accident victim was involved in a motor vehicle accident; or an accident arising from the use or operation of motor vehicle s/he will have access to accident benefits to pay for these services.
The level of accident benefits available to each person varies depending on the coverage purchased under the policy along with the degree of injury. For the most minor accidents, people will only have access to $3,500 in benefits. For more serious accidents there is a blended level of $65,000. For the most serious accidents, there is $1,000,000 available in coverage.
But what happens for those people who have no coverage?
What happens if the insurance company refuses to pay for treatment?
These are very good questions because these scenarios arise very frequently. Not everyone who has been hurt gets hurt in a motor vehicle accident. And not every accident benefit insurer will approve benefits to assist in your wellness and rehabilitation.
In these circumstances, the injured party has few options:
They can pay for treatment out of pocket, and hope to get reimbursed at the end of the case by the at fault party for their out of pocket treatment expenses. This can be a very expensive option, and getting all of your money back is never guaranteed.
The person can do nothing and do their best to work within the OHIP system as best as they can. Some physio clinics across the province are subsidized by OHIP thus they bill at much lower rates than you would see on the open market.
The person can also seek a service provider to take on their treatment on a protected account basis. In this case the accident victim makes a promise to pay for the incurred treatment upon settlement of their case. The service provide will request that the person sign a document like a “Promise to Pay” or an “Irrevocable Direction” which states that the client agrees to pay for the services incurred.
The benefit to this is that the accident victim receives treatment, no questions asked and no hoops to jump through to get those services. Those hoops which are avoided are things like Insurance Examinations, completing paperwork for approvals, or being limited to an insurer’s service platform with respect to what services are insurable and what services are not. If you want something, you get it. All you need to do is pay for those services at the end. The fact that the accident victim receives treatment can greatly assist in their recovery.
In these arrangements, the service provider will get your personal injury lawyer involved in some capacity. The service provider will send a copy of the paperwork you signed to your lawyer so that they understand what’s happening behind the scenes.
But be careful what you are signing up for!
Think of this arrangement like going to a bar (pre-COVID of course); giving the bartender your credit card and running up a tab. It’s nice while the drinks are flowing. But at the end of the night when the music stops, someone needs to pay the bar bill. And when you look at the bar tab at the end of the night, often it’s not pretty. If you run up the tab too high, it’ll put a big dent in your wallet.
The same applies to a personal injury case. If your treatment bill runs up too high, it can often wipe out or even eclipse the value of your award.
Responsible service providers will be careful not to run up the treatment bill too high. But there are some service providers who just aim to treat, treat, treat and in turn bill, bill, bill. The client doesn’t know how much all of the treatment will cost, so they just keep going because that what their service provider says to do. You don’t want to be in this sort of situation, particularly if you aren’t benefiting from the treatment.
Often insurers frown upon these arrangements. They are skeptical that the treatment is reasonable, necessary, or that the client is benefiting from the treatment incurred. The treatment sometimes is not proportional to the injuries sustained. Or the treatment is being used in part on the injured body part; and in part of injured parts of the body which are not related to the subject accident.
The service provider will also not take in to consideration other issues for the case which would reduce the claim’s value. Things like contributory negligence, liability, any coverage issues, any credibility issues or pre-exisiting health are often not taken in to consideration at all by a service provider. These are major issues which can impact he value of a case regardless of how much treatment has been incurred. If a Plaintiff is 50% responsible for his/her accident, will a service provider reciprocate and reduce their treatment bill by 50%? What happens if that number is 75%? What happens if there is a limited pot of money from which the Plaintiff can collect? Someone will have to take a haircut and it’s often the Plaintiff who losses out. The award they expected to receive is reduced significantly by an account they never see until the very end.
Lesson? Be careful what you sign. Ask for updated payment statements from your service provider and make sure that recovery for both you and the service provider is a realistic option.