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“Minor injury”
procedures in Alberta for Motor Vehicle Accidents occurring
after October 1, 2004 Insurance Reform |
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| Prepared By
Gregory J. Alexander |
The content of this article is intended to be informational
only. We caution you against using or relying upon any information
contained in this article without first seeking legal advice
regarding your particular matter. All matters arising from the use
of our website, including this article, shall be governed by
Alberta law and shall be within the exclusive jurisdiction of the
courts of Alberta.
Introduction
Section B “no fault” coverage
Section B of the Standard Policy
provides for benefits which may be claimed by automobile occupants,
or pedestrians that have been struck by an automobile, regardless of
whether they are at fault in the accident. Those benefits include
medical payment, death, grief counseling and funeral benefits, and
total disability wage replacement benefits. The Medical Payments
coverage reads as follows:
“In
respect of injuries to which the Diagnostic and Treatment
Protocols Regulation applies and that are diagnosed and treated
in accordance with the protocols under that Regulation, the expenses
payable for any service, diagnostic imaging, laboratory testing,
specialized testing, supply, treatment, visit, therapy, assessment
or making a report, or any other activity or function authorized
under that Regulation…to the limit of $50,000.00 per person”.
Notwithstanding the $50,000.00
limit mentioned, there are further limitations in respect of
chiropractic services ($750.00) massage therapy ($250.00) and
acupuncture ($250.00), all per person.
To complicate matters, there are
further provisions for medical payment coverage for injuries:
i.
to which the diagnostic and treatment protocols regulation
applies but that are not diagnosed and treated in accordance with
the protocols under that regulation;
ii.
to which the diagnostic and treatment protocols regulation
ceases to apply but for which the insured person wishes to make a
claim under provision (3) of “special provisions, definitions, and
exclusions of section B”; and
iii.
to which section B applies other than those injuries referred
to in sub-clauses I and ii.
In those
instances, the coverage is for:
“all
reasonable expenses incurred within two years from the date of the
accident as a result of those injuries for necessary medical,
surgical, chiropractic, dental, hospital, psychological, physical
therapy, occupational therapy, massage therapy, acupuncture,
professional nursing and ambulance services and, in addition, for
other services and supplies that are, in the opinion of the insured
person’s attending physician and in the opinion of the Insurer’s
medical advisor, essential for the treatment or rehabilitation of
the injured person, to the limit of $50,000.00 per person”.
Definition of “minor injury”
A minor injury is defined as an
injury to tendons, ligaments, or muscles, or a whiplash-associated
disorder (“WAD injury”), that does not result in a serious
impairment to the injured person. This means the injury does not
cause an impairment of a physical or cognitive function that results
in a substantial inability to perform the essential tasks of
employment or education, or normal activities of daily living. A
WAD injury is not categorized as minor if it exhibits certain
neurological signs, or a fracture to or dislocation of the spine.
An otherwise non-minor injury
can be deemed to be “minor” as a result of certain behavior of the
injured person, including: failing to attend an assessment, refusing
to answer relevant questions, failing to release relevant
diagnostic, treatment, or care information, obstructing an
assessment, and failing, without excuse to follow the Treatment
Protocols.
The ultimate determination of
whether an injury is minor or not is determined through an
examination by a Certified Examiner, which occurs after the
Treatment Protocols have been followed, and after 90 days.
Diagnostic and Treatment Protocols
Summary of time deadlines
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Within 10 days of accident, or as soon as
practicable thereafter, if possible minor injury, claimant to see
Health Care Practitioner and submit Notice and Proof of Claim form
to insurer;
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Within 5 further business days, insurer must
accept or deny the claim;
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Within 30 days of accident – in the case of non
minor injury claims, claimant must submit Notice and Proof of Claim
form to insurer;
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During first 90 days following accident in the
case of a minor injury, treatment in accordance with the Protocols.
Insurer cannot request any other form of treatment or medical
information;
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After 90 days following the accident, if
Protocols followed, and disagreement as to classification of injury,
either party may give notice requesting examination by named
Certified Examiner;
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Within 14 days of notice, other party shall
accept or reject (and provide name of alternative Certified
Examiner);
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If no agreement, either party may apply to the
Superintendent of Insurance;
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Within 5 days, Superintendent must select a
different Certified Examiner;
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Within 30 days of selection, appointment with
Certified Examiner to occur;
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Within 30 days of examination, Certified Examiner
to provide opinion, or request a further assessment;
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Within 6 months of first assessment, second
examination must take place.
Forms and Resources
Access to the pertinent
regulations, forms, and further information can be obtained at the
government website at
http://www.finance.gov.ab.ca/publications/insurance/index.html#consumer
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