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no-fault benefits – BC INJURY LAW
Tag: no-fault benefits
BC Supreme Court Finds Botox Covered Under ICBC's Part 7 Benefits
Written by admin on November 24, 2010 . Posted in ICBC No-Fault (Part 7) Benefits, Uncategorized.
It is not uncommon for physicians to occasionally prescribe Botox Injections to treat symptoms of pain following motor vehicle collisions. The Botox itself is not covered by the BC Medical Service Plan and people often turn to ICBC for funding of this expense. Two recent decisions have addressed whether ICBC is obliged to fund Botox therapy when prescribed by a physician.
In 2008 Mr. Justice Macaulay provided reasons for judgement (Tiessen v. ICBC) finding that Botox is indeed a covered benefit under ICBC’s No-Fault Plan. The Court provided the following reasons:
[] Counsel for ICBC seeks to impose too high a standard for proving that a recommended treatment is necessary. I am satisfied that the treatment is necessary in the sense that the plaintiff needs short and long term pain relief for his lower back. While it is impossible to predict that this particular treatment will succeed, it is nonetheless, on the evidence before me, a necessary physical treatment within the meaning of the section.
[] There is no evidence to suggest that the proposed cost of the staged treatment is unreasonable. The fact that the particular treatment is not covered by MSP does not establish that the cost is unreasonable.
[] I am persuaded that the plaintiff is entitled to a declaration that he is an insured person to be benefited pursuant to Part 7 of the Regulations and a further declaration that he is entitled to receive medical rehabilitative benefits pursuant to the contract of insurance with the defendant under Policy Number 639 DER for the cost of Botox injections as recommended by Dr. Quartly.
Further reasons for judgement were released today by the BC Supreme Court, Vancouver Registry, confirming that Botox is a benefit covered under Part 7.
In today’s case (Plensky v. Di Biase) the Plaintiff was injured in a 2004 motor vehicle collision. A jury awarded the Plaintiff damages including just over $60,000 for the cost of her future medical care. The court was then asked to reduce the award to take into account the future expenses that were covered directly by the Plaintiff’s Part 7 Benefits to avoid “double recovery” (You can click here to read more about this topic). Madam Justice Ross ultimately made a modest deduction to the Jury’s award. Part of the deduction reflected the cost of future Botox injections which the Court accepted was a responsibility of ICBC’s under the Plaintiff’s Part 7 Benefits.
Today’s case coupled with Mr. Justice Macaulay’s 2008 decision make it clear that Botox can be covered under people’s own policies of ICBC Insurance.
A Suggested Change at ICBC To Benefit British Columbians
Written by admin on October 13, 2010 . Posted in ICBC No-Fault (Part 7) Benefits, Tort Reform, Uncategorized. 71 Comments
Whether you are a plaintiff lawyer, a defence lawyer, an adjuster or someone insured with ICBC I think we can all agree that there is one ICBC practice that could change to better serve British Columbians. I’m talking about the practice of assigning the same adjuster to deal with Tort and No-Fault Benefit claims.
As I’ve previously discussed, ICBC usually fulfills two roles in the context of injury claims. The first is that they insure people for “no-fault” benefits. If you are insured, whether or not you are at fault for a collision ICBC provides some basic coverage for medical/rehabilitation expenses and a modest wage loss benefit in the event of total disability. If you are seeking coverage ICBC assigns an adjuster to process your claim no-fault benefits.
At the same time ICBC usually provides coverage to the at fault party for any claims made against them. When a faultless party is injured and wishes to be compensated for the full extent of their damages they make a tort claim. ICBC assigns an adjuster to process these tort claims. The difficulty, however, is that ICBC typically assigns the same adjuster to deal with the faultless parties claims for no-fault benefits and to process the tort claim made against the at fault party.
As a business decision ICBC’s policy makes sense. Why assign two people to look after various claims being advanced as a result of a single event? It is more cost effective to get one adjuster to learn about the crash, the parties involved, the various injuries and the claims being advanced. As a practical matter, however, one person cannot fulfill both these roles in a completely impartial way.
In reality adjusters processing a no-fault benefits claim have a very different duty compared to an adjuster processing a tort claim. In a no-fault benefits claim the adjuster owes a duty to the injured party to provide them with their insurance benefits. If therapies are required these should be covered. If disability occurs wage loss benefits should be provided.
In tort claims, however, the adjuster owes a duty to the at fault party. If claims are being advanced the at fault party will want those settled for as little as possible as the funds are paid from their coverage. It is difficult to imagine how one adjuster can fulfill these competing duties fairly and impartially. The conflicting duties create an inherent conflict of interest. (You can click here to read an article providing a real world example of how this conflict can play out to harm the interests of a person injured through no fault of their own).
After reading this you may be asking yourself whether ICBC’s practice is lawful. Unfortunately, the answer is yes. This practice has been brought before the Courts and is tolerated.
However, just because a practice is accepted does not make it right. Since the Courts are not able to correct this practice the ability to change is in the hands of ICBC.
The solution is simple. ICBC can assign separate adjusters to deal with tort and no-fault claims. Once done ICBC can set up internal ‘walls’ to prevent the adjusters from accessing each others files. This would add more fairness to the application process for no-fault benefits. This would also help ensure that information shared by a party with their insurer to receive medical treatment is not automatically disclosed to the agent of the person responsible for causing the injuries. This is a proposed change, I hope, we could all agree on.
As always, feedback is welcome on this forum and I’d appreciate views from others about this topic, particularly views from people who feel these proposed changes would not be beneficial.
ICBC Part 7 Benefits and the Definition of Vehicle "Occupant"
Written by admin on October 22, 2009 . Posted in ICBC No-Fault (Part 7) Benefits, Uncategorized. 59 Comments
Reasons for judgment were released today involving a tragic BC Pedestrian/Truck Crash addressing an injured Plaintiff’s entitlement to “no-fault” accident benefits.
In today’s case (Schuk v. York Fire & Casualty Insurance Company) the Plaintiff was outside of the vehicle (which was hauling a trailer) she was riding in for the purpose of putting chains on it. While doing so she was struck by a tractor-trailer unit and suffered catastrophic injuries. Her vehicle and the various trailers of the vehicles involved were insured with different companies. The Plaintiff applied for ‘no-fault‘ accident benefits to all of the insurers and they all refused payment because they could not agree which of them was responsible for paying the benefits.
The obligation for ICBC to pay no-fault benefits turns in part on whether a person is “insured“. The definition of an “insured” is contained in s. 78 of the Insurance (Vehicle) Regulation and includes “an occupant of a vehicle that is licenced in the Province…” and “a pedestrian who collides with a vehicle described in an owner’s certificate” The determination of which insurer was ultimately responsible to pay the Plaintiff her benefits turned on whether she was an “occupant” of her vehicle at the time of this accident or a “pedestrian“.
Mr. Justice Myers held that the Plaintiff was a “pedestrian” and in so doing made the following observations with respect to the test for being an “occupant“:
[16] The Regulation defines occupant, but does not define pedestrian. Occupant is defined in s. 1(1) as follows:
“occupant” means a person operating or riding in a vehicle or camper and includes
(a) a person entering or alighting from a vehicle or camper, and
(b) a person, other than a garage service operator or an employee of a garage service operator, who is working, or whose dependant is working, in or on a vehicle or camper owned by that person;
[17] There are a large number of cases which have addressed this issue in factual situations similar or analogous to the case at bar. For example, in Kyriazis v. Royal Insurance Co. of Canada (1991), 82 D.L.R. (4th) 691 (Ont. Gen. Div.), affirmed (1993), 107 D.L.R. (4th) 288 (C.A.), the plaintiff pulled his car over to clean the snow off its windshield. Abbey J. held that he was not an occupant. In doing so, Abbey J. rejected a line of authority – primarily from the United States – which applied what was referred to as a “zone of connection test”. That test regarded the intent of the injured person as a significant determining factor of whether he or she was an occupant when not inside the vehicle. Abbey J. focussed on the definition of occupant contained in the insurance policy before him, which was virtually identical to that in the Regulation. He stated:
The word “occupant” is defined by reference to various physical activities or processes. An “occupant” is a person who is driving an automobile, being carried in or upon an automobile, entering or getting onto an automobile or alighting from an automobile. The plain meaning of the words used, it seems to me, suggests an intention to draw the line between an occupant and a non-occupant at the point that an individual, who is not driving, can no longer be said to be either entering or getting on to an automobile or, alternatively, alighting from an automobile…
[22] However, the definition of “occupant” in the Regulation, and the definition in the policies involved in the other cases I have cited above, do in fact refer to the activity of driving, or getting in or out of a vehicle. On that basis, I do not see a reason for departing from the approach in Kyriazis and the other cases I have cited above.
[23] Ms. Schuk was not operating or riding in the vehicle, entering into it, nor alighting from it at the time of the accident. Although the purpose of pulling over and getting out the vehicle was to put chains on it, the parties are in accord that Ms. Schuk was not actually working on the vehicle at the time of the collision. Therefore none of the criteria for an occupant contained in the definition are met and she was not an occupant.
[24] Pedestrian is not defined. However, that was also so in most of the cases I cited above at para. 18. The approach taken in those cases is that for the purposes of the scheme of automobile insurance, a victim of a car accident is either an occupant or a pedestrian; in other words if the victim does not fall within the definition of a passenger, then she is an occupant. That appears to me to be the case with the legislation and regulation in issue in the case at bar. Accordingly Ms. Schuk was a pedestrian at the time of the accident.
[25] Ms. Shuk was therefore an insured for the purpose of no-fault benefits under both MPIC and ICBC coverage.