What are the Medical expenses covered?

The Section B benefits will pay for all reasonable medical and rehabilitation expenses that are necessary as a result of the car accident. These expenses include ambulance bill, physiotherapy, massage therapy, chiropractic care, nursing care, psychological counselling, medical equipment such as wheel chairs, walkers, crutches and orthopedic soles and shoes, gym memberships, and home modifications. It is important to note that medical and rehabilitation expenses are subject to a 4 year time limit and a maximum of $50,000.00 per person.

Which type of Medical Treatment is covered?

When the insured party survives a car collision but requires treatments, the insurance policy provides for medical coverage. The treatments covered are defined as follows in the contract:

(1) The insurer will pay with respect to each insured person who sustains bodily injury as a result of an accident reasonable expenses resulting from the accident within the benefit period set out in clause (2) for,

  1. necessary medical, surgical, dental, chiropractic, ambulance, hospital, or professional nursing services;
    (also known as category 1)
  2. any other necessary service within the meaning of entitled services in the Hospital Services Act or the Medical Services Payment Act; and
    (also known as category 2)
  3. other goods and services, which, in the opinion of the insured person’s attending physician and in the opinion of the insurer’s medical advisor, are essential for the treatment, occupational retraining or rehabilitation of the insured person.
    (also known as category 3)

[…]

(4)  Medical services mentioned in subclause (a) of clause (1) means services;

  1. performed by a physician, or
  2. performed by a duly qualified health professional and prescribed by a physician as necessary for the treatment of the person.

Medical Coverage – Category 1 & 2

The New Brunswick Court of Appeal has been called upon to address the scope of the treatments covered in a case where the insurer refused to cover massage therapy services: Rolfe v. Axa Insurance Co., 2004 NBCA 14. The unanimous bench concluded that ‘medical services’ has an expansive meaning which extends to massage therapy and were thus a category 1 expense. This determination is of consequence as the insurer’s medical advisor has no say for the payment of those expense (paras 6-8 & 68; Webb v. Aviva Insurance Co., 2011 NBQB 98 para 22). Although not part of the ratio in Rolfe, supra, the unanimous bench also recognized “that expenses incidental to the procurement of Subsection 1(1) services, such as the cost of related meals, lodging and transportation, are covered” (para 25). Physiotherapy services are a category 1 medical service: Lamrock v. Wellington Insurance Co. (1999), 222 NBR (2d) 374 para 13-16 (QB). The insurer may require credentials for the professionals providing services: Davidson v. Medavie Blue Cross, 2011 NBQB 378 paras 17-20. Babysitting and Household cleaning services are not a category 1 expense, even if prescribed by a physician: Solomon v. Portage La Prairie Mutual Insurance Co., 1993 CanLII 8205 para 6 (QB). Furthermore, expenses for medical assessments incurred by the insured without the knowledge and approval of the insurer, to advance a claim against a third party, are not captured by the provision even if of a category 1: Veno v. United General Insurance Corp., 2008 NBCA 39 para 91.

Medical Coverage – Category 3

Regarding the other ‘goods and services’ (category 3), covered on the advice of the attending physician and the insurer’s medical advisor, the provision is not expressly limited to medical elements. Although a treadmill was disallowed in Veno, supra, because the attending physician and medical advisor deemed it unnecessary, it likely would have been an admissible expense otherwise. In Solomon, supra para 6, Justice Godin expressed the opinion, in addition to babysitting and housecleaning services not being “prescription expenses”, that they were neither “legitimate expenses”. Hence, a court may be inclined to view such services as not “essential for the treatment, occupational retraining, or rehabilitation of the insured person”. The unanimous Court of Appeal has also refused to consider college tuition as a legitimate category 3 retraining or rehabilitation expense: Joynes v. Canadian Home Insurance Co (1989), 96 NBR (2d) 433 (CA).

Although the insurance contract provides hat only category 3 medical expenses are payable on the advice of the attending physician and the insurer’s medical advisor.

Can Insurer Send You to their Medical Examiner?

There is a general right on insurers to obtain professional advices. Clause (5) of the Special Provisions states:

(5) MEDICAL REPORTS

The insurer has the right and the claimant shall afford to the insurer, an opportunity to examine the person of the insured person when and as often as it reasonably requires while the claim is pending, and also, in the case of the death of the insured person, to make an autopsy subject to the law relating to autopsies.

Evidently, “the insurance company has a legitimate self-interest in determining that it is making payments for measures that are remedying a situation for which the accident in question was the cause”: Lamrock, supra para 18. That interest applies to the medical and loss of income benefits: Veno, supra para 109. However, as stated in the provision, the insurer must act ‘reasonably’. Compelling injured persons to travel outside of the province for an examination is questionable: Wheaton v. Mellish (1989), 103 NBR (2d) 271 (QB); Perreault v. Ramsay (1994), 150 NBR (2d) 91 (CA). Furthermore, when the insurer exercises its right, “one would expect the choice [of the examiner] to be that of a specialist in the nature of injury suffered by the insured” (Lamrock, supra para 20) but is not necessary that the examiner be a physician (Veno, supra paras 103-110). Grounds that may justify an objection to an examination are risky or painful invasive procedures, the extent of any hardship or inconvenience suffered, the qualifications of the examiner, or a prior bad experience with the professional: LeClerc v. Sunbury Transport Ltd (1992), 124 NBR (2D) 433 PARA 15 (CA).

Does Section B Insurer pay Medical Expenses if I have other Medical Insurance Plans such as Blue Cross?

The Section B medical coverage is in addition to other medical insurance plans. When available, the insured must first obtain reimbursement of his or her expenses through other insurers, before submitting the balance to Section B: Rolfe, supra para 63.