jswizzle3737/ontario_laws_and_regs huggingface dataset:
Citation
 1. This Regulation may be cited as the Statutory Accident Benefits Schedule — Effective September 1, 2010.  O. Reg. 34/10, s. 1.
PART II INCOME REPLACEMENT, NON-EARNER AND CAREGIVER BENEFITS
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Income Replacement Benefits
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Eligibility criteria
 5. (1) The insurer shall pay an income replacement benefit to an insured person who sustains an impairment as a result of an accident if the insured person satisfies one or both of the following conditions: 1.  The insured person, i.  was employed at the time of the accident and, as a result of and within 104 weeks after the accident, suffers a substantial inability to perform the essential tasks of that employment, or ii.  was not employed at the time of the accident but, A.  was employed for at least 26 weeks during the 52 weeks before the accident or was receiving benefits under the Employment Insurance Act (Canada) at the time of the accident, B.  was at least 16 years old or was excused from attending school under the Education Act at the time of the accident, and C.  as a result of and within 104 weeks after the accident, suffers a substantial inability to perform the essential tasks of the employment in which the insured person spent the most time during the 52 weeks before the accident. 2.  The insured person, i.  was a self-employed person at the time of the accident, and ii.  suffers, as a result of and within 104 weeks after the accident, a substantial inability to perform the essential tasks of his or her self-employment.  O. Reg. 34/10, s. 5 (1). (2) Despite subsection (1), an insured person is not eligible to receive income replacement benefits if he or she is eligible to receive and has elected under section 35 to receive either a non-earner benefit or a caregiver benefit under this Part.  O. Reg. 34/10, s. 5 (2).
Period of benefit
 6. (1) Subject to subsection (2), an income replacement benefit is payable for the period in which the insured person suffers a substantial inability to perform the essential tasks of his or her employment or self-employment.  O. Reg. 34/10, s. 6 (1). (2) The insurer is not required to pay an income replacement benefit, (a)  for the first week of the disability; or (b)  after the first 104 weeks of disability, unless, as a result of the accident, the insured person is suffering a complete inability to engage in any employment or self-employment for which he or she is reasonably suited by education, training or experience.  O. Reg. 34/10, s. 6 (2).
Amount of weekly income replacement benefit
 7. (1) The weekly amount of an income replacement benefit payable to an insured person who becomes entitled to the benefit before his or her 65th birthday is the lesser of “A” and “B” where, “A”  is the weekly base amount determined under subsection (2) less the total of all other income replacement assistance, if any, for the particular week the benefit is payable, and “B”  is $400 or, if an optional income replacement benefit referred to in section 28 has been purchased and applies to the person, the amount fixed by the optional benefit.  O. Reg. 34/10, s. 7 (1). (2) For the purposes of subsection (1), the weekly base amount in respect of an insured person is determined as follows: 1.  Determine whichever of the following amounts is applicable: i.  70 per cent of the amount, if any, by which the sum of the insured person’s gross weekly employment income and weekly income from self-employment exceeds the amount of the insured person’s weekly loss from self-employment, if the weekly income replacement benefit is for one of the first 104 weeks of disability, or ii.  the greater of the amount determined for the purposes of subparagraph i and $185, if the weekly income replacement benefit is for a week for which the person is entitled to receive an income replacement benefit after the first 104 weeks of disability. 2.  To the amount determined under paragraph 1, add 70 per cent of the amount of the insured person’s weekly loss from self-employment that he or she incurs as a result of the accident.  O. Reg. 34/10, s. 7 (2). (3) The insurer may deduct from the amount of an income replacement benefit payable to an insured person, (a)  70 per cent of any gross employment income received by the insured person as a result of being employed after the accident and during the period in which he or she is eligible to receive an income replacement benefit; and (b)  70 per cent of any income from self-employment earned by the insured person after the accident and during the period in which he or she is eligible to receive an income replacement benefit.  O. Reg. 34/10, s. 7 (3). (4) The insurer shall pay an expense incurred by or on behalf of an insured person for the preparation of a report for the purpose of calculating the person’s income from employment or self-employment if all of the following conditions are satisfied: 1.  The insured person is applying for an income replacement benefit under this Part that is based on the employment or self-employment considered in the report. 2.  The report is prepared by a member of a designated body within the meaning of the Public Accounting Act, 2004. 3.  The expense is reasonable and necessary for the purpose of determining the insured person’s entitlement to an income replacement benefit.  O. Reg. 34/10, s. 7 (4); O. Reg. 289/10, s. 2. (5) The insurer is not required to pay more than a total of $2,500 for the preparation of one or more reports under subsection (4) in respect of an insured person.  O. Reg. 34/10, s. 7 (5).
Adjustment after age 65
 8. (1) If a person is receiving an income replacement benefit immediately before his or her 65th birthday, the weekly amount of the benefit is adjusted, on the later of the day of the person’s 65th birthday and the second anniversary of the day the person began receiving the benefit, to the amount determined in accordance with the following formula: C × 0.02 × D in which, “C”  is the weekly amount of the income replacement benefit that the person was entitled to receive immediately before the adjustment, before any deductions permitted by subsection 7 (3), “D”  is the lesser of, (a)  35, and (b)  the number of years during which the person qualified for the income replacement benefit before the adjustment is made. O. Reg. 34/10, s. 8 (1). (2) Despite section 6, an income replacement benefit that has been adjusted under subsection (1) is payable, without any deductions under clause 7 (3) (a) or (b), until the person dies.  O. Reg. 34/10, s. 8 (2).
If entitlement first arises on or after 65th birthday
 9. (1) If an insured person becomes entitled to receive an income replacement benefit on or after his or her 65th birthday, (a)  subject to clause 6 (2) (a) and despite clause 6 (2) (b), the insured person is entitled to an income replacement benefit for not more than 208 weeks after becoming entitled to the benefit; and (b)  the weekly amount of the benefit is the weekly amount of the income replacement benefit otherwise determined under section 7 before any deductions permitted by subsection 7 (3), multiplied by the factor set out in Column 2 of the Table to this subsection opposite the number of weeks that have elapsed since the person became entitled to receive the benefit. TABLE  Column 1   Number of weeks since Entitlement Arose    Column 2   Factor 

  Less than 52 weeks   1.0 

  52 weeks or more but less than 104 weeks   0.8 

  104 weeks or more but less than 156 weeks   0.6 

  156 weeks or more but less than 208 weeks   0.3 O. Reg. 34/10, s. 9 (1). (2) No deduction may be made under clause 7 (3) (a) or (b) from an income replacement benefit determined under subsection (1).  O. Reg. 34/10, s. 9 (2).
No violation of Human Rights Code
 10. The age distinctions in sections 8 and 9 apply despite the Human Rights Code.  O. Reg. 34/10, s. 10.
Temporary return to employment
 11. A person receiving an income replacement benefit may return to or start employment or self-employment at any time during the first 104 weeks for which he or she is receiving the benefit without affecting his or her entitlement to resume receiving any benefits to which he or she is entitled under this Part if, as a result of the accident, he or she is unable to continue the employment or self-employment.  O. Reg. 34/10, s. 11. Non-Earner Benefits
Non-Earner Benefits
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12.
 12. (1) The insurer shall pay a non-earner benefit to an insured person who sustains an impairment as a result of an accident if the insured person satisfies any of the following conditions: 1.  The insured person suffers a complete inability to carry on a normal life as a result of and within 104 weeks after the accident and does not qualify for an income replacement benefit. 2.  The insured person suffers a complete inability to carry on a normal life as a result of and within 104 weeks after the accident and, i.  was enrolled on a full-time basis in elementary, secondary or post-secondary education at the time of the accident, or ii.  completed his or her education less than one year before the accident and was neither employed nor a self-employed person after completing his or her education and before the accident, in a capacity that reflected his or her education and training.  O. Reg. 34/10, s. 12 (1). (2) The amount of a non-earner benefit is $185 for each week during the period that the insured person suffers a complete inability to carry on a normal life, less the total of all other income replacement assistance, if any, for the same week.  O. Reg. 34/10, s. 12 (2); O. Reg. 251/15, s. 4 (1). (3) The insurer is not required to pay a non-earner benefit, (a)  for the first four weeks after the onset of the complete inability to carry on a normal life; (b)  before the insured person is 18 years of age; (c)  for more than 104 weeks after the accident; or (d)  if the insured person is eligible to receive and has elected under section 35 to receive either an income replacement benefit or a caregiver benefit under this Part. O. Reg. 251/15, s. 4 (2). (4), (5) Revoked: O. Reg. 251/15, s. 4 (2). Caregiver Benefits
Caregiver Benefits
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13.
 13. (1) The insurer shall pay a caregiver benefit to or for an insured person who sustains a catastrophic impairment as a result of an accident if, as a result of and within 104 weeks after the accident, the insured person suffers a substantial inability to engage in the caregiving activities in which he or she was engaged at the time of the accident and if, at the time of the accident, (a)  the insured person was residing with a person in need of care; and (b)  the insured person was the primary caregiver for the person in need of care and did not receive any remuneration for engaging in caregiving activities.  O. Reg. 34/10, s. 13 (1). (2) The caregiver benefit shall pay for reasonable and necessary expenses incurred as a result of the accident in caring for a person in need of care, but shall not exceed, (a)  $250 per week for the first person in need of care; and (b)  $50 per week for each additional person in need of care.  O. Reg. 34/10, s. 13 (2). (3) Despite subsection (1), no caregiver benefit is payable to an insured person if he or she is eligible to receive and has elected under section 35 to receive either an income replacement benefit or a non-earner benefit under this Part.  O. Reg. 34/10, s. 13 (3). (4) Despite subsection (1), no caregiver benefit is payable for any period longer than 104 weeks of disability unless, as a result of the accident, the insured person is suffering a complete inability to carry on a normal life.  O. Reg. 34/10, s. 13 (4). PART III   MEDICAL, REHABILITATION AND ATTENDANT CARE BENEFITS
PART III MEDICAL, REHABILITATION AND ATTENDANT CARE BENEFITS
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14.
 14. Except as otherwise provided in this Regulation, an insurer is liable to pay the following benefits to or on behalf of an insured person who sustains an impairment as a result of an accident: 1.  Medical and rehabilitation benefits under sections 15 to 17. 2.  If the impairment is not a minor injury, attendant care benefits under section 19.  O. Reg. 34/10, s. 14.
15.
 15. (1) Subject to section 18, medical benefits shall pay for all reasonable and necessary expenses incurred by or on behalf of the insured person as a result of the accident for, (a)  medical, surgical, dental, optometric, hospital, nursing, ambulance, audiometric and speech-language pathology services; (b)  chiropractic, psychological, occupational therapy and physiotherapy services; (c)  medication; (d)  prescription eyewear; (e)  dentures and other dental devices; (f)  hearing aids, wheelchairs or other mobility devices, prostheses, orthotics and other assistive devices; (g)  transportation for the insured person to and from treatment sessions, including transportation for an aide or attendant; and (h)  other goods and services of a medical nature that the insurer agrees are essential for the treatment of the insured person, and for which a benefit is not otherwise provided in this Regulation. O. Reg. 34/10, s. 15 (1); O. Reg. 251/15, s. 5. (2) Despite subsection (1), the insurer is not liable to pay medical benefits, (a)  for goods or services that are experimental in nature; (b)  for expenses related to goods and services described in subsection (1) rendered to an insured person that exceed the maximum rate or amount of expenses established under the Guidelines, other than for expenses related to the services described in clause (1) (g); or (c)  for transportation expenses other than authorized transportation expenses.  O. Reg. 34/10, s. 15 (2); O. Reg. 14/13, s. 1.
17.
 17. (1) Subject to subsection (2), medical or rehabilitation benefits shall pay for all reasonable and necessary expenses incurred by or on behalf of an insured person as a result of the accident for services provided by a qualified case manager in accordance with a treatment and assessment plan under section 38, (a)  if the insured person sustains a catastrophic impairment as a result of the accident; or (b)  if the optional medical, rehabilitation and attendant care benefit referred to in paragraph 4 of subsection 28 (1) or the catastrophic impairment benefit referred to in paragraph 5 of subsection 28 (1) is available to the insured person. O. Reg. 34/10, s. 17 (1); O. Reg. 251/15, s. 7. (2) The insurer is not liable to pay expenses for case manager services that exceed the maximum rate or amount of expenses established under the Guidelines.  O. Reg. 34/10, s. 17 (2). (3) In this section, “qualified case manager” means a person who provides services related to the co-ordination of goods or services for which payment is provided by a medical, rehabilitation or attendant care benefit.  O. Reg. 34/10, s. 17 (3); O. Reg. 289/10, s. 3.
18.
 18. (1) The sum of the medical and rehabilitation benefits payable in respect of an insured person who sustains an impairment that is predominantly a minor injury shall not exceed $3,500 plus the amount of any applicable harmonized sales tax payable under Part IX of the Excise Tax Act (Canada)
for accidents that occur on or after June 3, 2019 for any one accident, less the sum of all amounts paid in respect of the insured person in accordance with the Minor Injury Guideline.  O. Reg. 34/10, s. 18 (1); O. Reg. 123/19, s. 2 (1). (2) Despite subsection (1), the limit in that subsection does not apply to an insured person if his or her health practitioner determines and provides compelling evidence that the insured person has a pre-existing medical condition that was documented by a health practitioner before the accident and that will prevent the insured person from achieving maximal recovery from the minor injury if the insured person is subject to the limit or is limited to the goods and services authorized under the Minor Injury Guideline.  O. Reg. 34/10, s. 18 (2); O. Reg. 347/13, s. 1; O. Reg. 123/19, s. 2 (2). (3) The sum of the medical, rehabilitation and attendant care benefits paid in respect of an insured person who is not subject to the financial limit in subsection (1) shall not exceed, for any one accident, (a)  $65,000 plus the amount of any applicable harmonized sales tax payable under Part IX of the Excise Tax Act (Canada) for accidents that occur on or after June 3, 2019; or (b)  if the insured person sustained a catastrophic impairment as a result of the accident, $1,000,000 plus the amount of any applicable harmonized sales tax payable under Part IX of the Excise Tax Act (Canada) for accidents that occur on or after June 3, 2019. O. Reg. 251/15, s. 8 (1); O. Reg. 123/19, s. 2 (3, 4). (4) The maximum amounts set out in subsection (3) apply unless modified by any optional benefits that are available under paragraph 3, 4 or 5 of subsection 28 (1).  O. Reg. 34/10, s. 18 (4); O. Reg. 251/15, s. 8 (2). (5) For the purposes of subsections (1) and (3), medical, rehabilitation and, where applicable, attendant care benefits payable in respect of an insured person include all fees and expenses for conducting assessments and examinations and preparing reports in connection with any benefit or payment to or for an insured person under this Regulation, other than, (a)  fees in connection with any examination required by an insurer under section 44; and (b)  expenses in respect of a report referred to in subsection 7 (4).  O. Reg. 34/10, s. 18 (5); O. Reg. 251/15, s. 8 (3).
20.
 20. (1) Subject to subsection (2), no medical, rehabilitation and attendant care benefit is payable for expenses incurred, (a)  more than 260 weeks after the accident, in the case of an insured person who was at least 18 years of age at the time of the accident; or (b)  after the insured person’s 28th birthday, in the case of an insured person who was under 18 years of age at the time of the accident. O. Reg. 251/15, s. 10. (2) The time limits set out in subsection (1) do not apply in respect of an insured person, (a)  who sustains a catastrophic impairment as a result of the accident; or (b)  who is entitled to optional medical, rehabilitation and attendant care benefits under paragraph 4 of subsection 28 (1) or catastrophic impairments benefits under paragraph 5 of subsection 28 (1). O. Reg. 251/15, s. 10. PART IV   PAYMENT OF OTHER EXPENSES
PART IV PAYMENT OF OTHER EXPENSES
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21.
 21. (1) The insurer shall pay for up to $15,000 for lost educational expenses incurred by or on behalf of an insured person who sustains an impairment as a result of an accident if, (a)  at the time of the accident, the insured person was enrolled in a program of elementary, secondary, post-secondary or continuing education; and (b)  as a result of the accident, the insured person is unable to continue the program.  O. Reg. 34/10, s. 21 (1). (2) The insurer may require a person who applies for or is receiving benefits under this section to furnish a disability certificate as often as is reasonably necessary.  O. Reg. 34/10, s. 21 (2). (3) If an insurer requires a disability certificate, the person shall furnish a new disability certificate, completed as of a date after the date of the insurer’s request, within 15 business days after receiving the insurer’s request.  O. Reg. 34/10, s. 21 (3). (4) If the person fails to comply with subsection (3), no amount is payable for lost educational expenses until the person furnishes the completed disability certificate.  O. Reg. 34/10, s. 21 (4). (5) In this section, “lost educational expenses” means expenses incurred before the accident for tuition, books, equipment or room and board in respect of the program term or program year in which the insured person was enrolled at the time of the accident, if the expenses are related to the program that the insured person is unable to continue.  O. Reg. 34/10, s. 21 (5).
22.
 22. (1) If an insured person sustains an impairment as a result of an accident, the insurer shall pay for reasonable and necessary expenses incurred not more than 104 weeks after the accident by the following persons as a result of the accident in visiting the insured person during his or her treatment or recovery: 1.  The spouse, children, grandchildren, parents, grandparents, brothers and sisters of the insured person. 2.  An individual who was living with the insured person at the time of the accident. 3.  An individual who has demonstrated a settled intention to treat the insured person as a child of the individual’s family. 4.  An individual whom the insured person has demonstrated a settled intention to treat as a child of the insured person’s family.  O. Reg. 34/10, s. 22 (1). (2) The time limit of 104 weeks does not apply if the insured person sustained a catastrophic impairment as a result of the accident.  O. Reg. 34/10, s. 22 (2).
23.
 23. The insurer shall pay up to $100 per week for reasonable and necessary additional expenses incurred by or on behalf of an insured person as a result of an accident for housekeeping and home maintenance services if, as a result of the accident, the insured person sustains a catastrophic impairment that results in a substantial inability to perform the housekeeping and home maintenance services that he or she normally performed before the accident.  O. Reg. 34/10, s. 23.
24.
 24. The insurer shall pay for all reasonable expenses incurred by or on behalf of an insured person in repairing or replacing the following: 1.  Clothing worn by the insured person at the time of the accident that was lost or damaged as a result of the accident. 2.  Prescription eyewear, dentures, hearing aids, prostheses and other medical or dental devices that were lost or damaged as a result of the accident.  O. Reg. 34/10, s. 24.
25.
 25. (1) The insurer shall pay the following expenses incurred by or on behalf of an insured person: 1.  Reasonable fees charged for preparing a disability certificate if required under section 21, 36 or 37, including any assessment or examination necessary for that purpose. 2.  Fees charged in accordance with the Minor Injury Guideline by a person authorized by the Guideline for preparing a treatment confirmation form and for conducting an assessment or examination and preparing a report as authorized by the Guideline. 3.  Reasonable fees charged by a health practitioner for reviewing and approving a treatment and assessment plan under section 38, including any assessment or examination necessary for that purpose, if any one or more of the goods, services, assessments or examinations described in the treatment and assessment plan have been: i.  approved by the insurer, ii.  deemed by this Regulation to be payable by the insurer, or iii.  determined to be payable by the insurer on the resolution of a dispute described in subsection 280 (1) of the Act. 4.  Reasonable fees charged by an occupational therapist or a registered nurse for preparing an assessment of attendant care needs under section 42, including any assessment or examination necessary for that purpose. 5.  Reasonable fees charged for preparing an application under section 45 for a determination of whether the insured person has sustained a catastrophic impairment, including any assessment or examination necessary for that purpose.  O. Reg. 34/10, s. 25 (1); O. Reg. 44/16, s. 2. (2) Despite subsection (1), an insurer is not required to pay for an assessment or examination conducted in the insured person’s home unless the insured person has sustained an impairment that is not a minor injury.  O. Reg. 34/10, s. 25 (2). (3) The insurer is not liable under subsection (1) for expenses related to professional services rendered to an insured person that exceed the maximum rate or amount of expenses established under the Guidelines.  O. Reg. 34/10, s. 25 (3); O. Reg. 14/13, s. 3. (4) The insurer shall pay reasonable expenses incurred by or on behalf of an insured person for authorized transportation expenses incurred in transporting the insured person to and from an assessment or examination referred to in subsection (1), including transportation expenses for an aide or an attendant.  O. Reg. 34/10, s. 25 (4). (5) Despite any other provision of this Regulation, an insurer shall not pay, (a)  more than a total of $2,000 plus the amount of any applicable harmonized sales tax payable under Part IX of the Excise Tax Act (Canada) for accidents that occur on or after June 3, 2019 in respect of fees and expenses for conducting any one assessment or examination and for preparing reports in connection with it, whether it is conducted at the instance of the insured person or the insurer; or (b)  any amount in respect of fees for preparing a future care plan, a life care plan or a similar plan or for any assessment or examination conducted in connection with the preparation of the plan.  O. Reg. 34/10, s. 25 (5); O. Reg. 289/10, s. 4; O. Reg. 123/19, s. 4. PART V   DEATH AND FUNERAL BENEFITS
PART V DEATH AND FUNERAL BENEFITS
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27.
 27. (1) The insurer shall pay a funeral benefit in respect of an insured person who dies as a result of an accident.  O. Reg. 34/10, s. 27 (1). (2) The funeral benefit shall pay for funeral expenses incurred in an amount not exceeding, (a)  $6,000; or (b)  if the optional death and funeral benefit referred to in section 28 has been purchased and is applicable to the insured person, the amount fixed by the optional benefit.  O. Reg. 34/10, s. 27 (2). PART VI   OPTIONAL BENEFITS
PART VI OPTIONAL BENEFITS
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29.
 29. (1) The optional dependant care benefit shall pay for reasonable and necessary additional expenses incurred by or on behalf of an insured person as a result of an accident in caring for the insured person’s dependants, if the insured person satisfies the following conditions: 1.  The insured person sustained an impairment as a result of the accident. 2.  The insured person was employed at the time of the accident. 3.  The insured person is not receiving a caregiver benefit.  O. Reg. 34/10, s. 29 (1). (2) Despite subsection (1), the amount of optional dependant care benefits shall not exceed $75 per week for the first dependant and $25 per week for each additional dependant, to a maximum amount of $150 per week.  O. Reg. 34/10, s. 29 (2). (3) No optional dependant care benefit is payable in respect of an expense incurred after the insured person dies.  O. Reg. 34/10, s. 29 (3).
PART VII GENERAL EXCLUSIONS
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PART VIII PROCEDURES FOR CLAIMING BENEFITS
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33.
 33. (1) An applicant shall, within 10 business days after receiving a request from the insurer, provide the insurer with the following: 1.  Any information reasonably required to assist the insurer in determining the applicant’s entitlement to a benefit. 2.  A statutory declaration as to the circumstances that gave rise to the application for a benefit. 3.  The number, street and municipality where the applicant ordinarily resides. 4.  Proof of the applicant’s identity.  O. Reg. 34/10, s. 33 (1). (2) If requested by the insurer, an applicant shall submit to an examination under oath, but is not required, (a)  to submit to more than one examination under oath in respect of matters relating to the same accident; or (b)  to submit to an examination under oath during a period when the person is incapable of being examined under oath because of his or her physical, mental or psychological condition.  O. Reg. 34/10, s. 33 (2). (3) An applicant is entitled to be represented at his or her own expense at an examination under oath by such counsel or other representative of his or her choice as the law permits.  O. Reg. 34/10, s. 33 (3). (4) The insurer shall make reasonable efforts to schedule the examination under oath for a time and location that are convenient for the applicant and shall give the applicant reasonable advance notice of the following: 1.  The date and location of the examination. 2.  That the applicant is entitled to be represented in the manner described in subsection (3). 3.  The reason or reasons for the examination. 4.  That the scope of the examination will be limited to matters that are relevant to the applicant’s entitlement to benefits.  O. Reg. 34/10, s. 33 (4). (5) The insurer shall limit the scope of the examination under oath to matters that are relevant to the applicant’s entitlement to benefits described in this Regulation.  O. Reg. 34/10, s. 33 (5). (6) The insurer is not liable to pay a benefit in respect of any period during which the insured person fails to comply with subsection (1) or (2).  O. Reg. 34/10, s. 33 (6). (7) Subsection (6) does not apply in respect of a non-compliance with subsection (2) if, (a)  the insurer fails to comply with subsection (4) or (5); or (b)  the insurer interferes with the applicant’s right to be represented as described in subsection (3).  O. Reg. 34/10, s. 33 (7). (8) If an applicant who failed to comply with subsection (1) or (2) subsequently complies with that subsection, the insurer, (a)  shall resume payment of the benefit, if a benefit was being paid; and (b)  shall pay all amounts that were withheld during the period of non-compliance, if the applicant provides a reasonable explanation for the delay in complying with the subsection.  O. Reg. 34/10, s. 33 (8). (9) Clause (2) (a) shall not be interpreted as prohibiting an additional examination of the applicant under oath, under Ontario Regulation 283/95 (Disputes Between Insurers) made under the Act, at the insurer’s request that is conducted for the purpose of determining who is liable under section 268 of the Act to pay statutory accident benefits in respect of the accident. O. Reg. 14/13, s. 4.
34.
 34. A person’s failure to comply with a time limit set out in this Part does not disentitle the person to a benefit if the person has a reasonable explanation.  O. Reg. 34/10, s. 34.
35.
 35. (1) If an application indicates that the applicant may qualify for two or more of the income replacement benefit, the non-earner benefit and the caregiver benefit under Part II, the insurer shall, within 10 business days after receiving the application, give a notice to the applicant advising the applicant that he or she must elect, within 30 days after receiving the notice, the benefit he or she wishes to receive.  O. Reg. 34/10, s. 35 (1). (2) If an applicant is determined to have sustained a catastrophic impairment as a result of an accident, the insurer shall, within 10 business days of the date of the determination, give a notice to the applicant advising the applicant that, despite any election previously made under subsection (1), he or she may elect, within 30 days after receiving the notice, to receive a caregiver benefit if the applicant would otherwise qualify for a caregiver benefit.  O. Reg. 34/10, s. 35 (2). (3) The applicant’s election under subsection (1) is final, regardless of any change in circumstances, and can be subsequently changed only if permitted under subsection (2).  O. Reg. 34/10, s. 35 (3); O. Reg. 347/13, s. 3. Claim for Income Replacement Benefit, Non-Earner Benefit, Caregiver Benefit or Payment for Housekeeping or Home Maintenance Services
Claim for Income Replacement Benefit, Non-Earner Benefit, Caregiver Benefit or Payment for Housekeeping or Home Maintenance Services
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36.
 36. (1) In this section and section 37, “specified benefit” means an income replacement benefit, non-earner benefit, caregiver benefit or a payment for housekeeping or home maintenance services under section 23.  O. Reg. 34/10, s. 36 (1). (2) An applicant for a specified benefit shall submit a completed disability certificate with his or her application under section 32.  O. Reg. 34/10, s. 36 (2). (3) An applicant who fails to submit a completed disability certificate is not entitled to a specified benefit for any period before the completed disability certificate is submitted.  O. Reg. 34/10, s. 36 (3). (4) Within 10 business days after the insurer receives the application and completed disability certificate, the insurer shall, (a)  pay the specified benefit; (b)  give the applicant a notice explaining the medical and any other reasons why the insurer does not believe the applicant is entitled to the specified benefit and, if the insurer requires an examination under section 44 relating to the specified benefit, advising the applicant of the requirement for an examination; or (c)  send a request to the applicant under subsection 33 (1) or (2).  O. Reg. 34/10, s. 36 (4). (5) If the insurer sends a request to the applicant under subsection 33 (1) or (2), the insurer shall, within 10 business days after the applicant complies with the request, (a)  pay the specified benefit; or (b)  give the applicant a notice described in clause (4) (b).  O. Reg. 34/10, s. 36 (5). (6) If the insurer fails to comply with subsection (4) or (5) within the applicable time limit, the insurer shall pay the specified benefit for the period starting on the day the insurer received the application and completed disability certificate and ending, if the insurer subsequently gives a notice described in subsection (4) (b), on the day the insurer gives the notice.  O. Reg. 34/10, s. 36 (6). (7) If the insurer requires the applicant to undergo an examination under section 44, the insurer shall, within 10 days after receiving the report of the examination, (a)  give a copy of the report to the applicant and to the person who completed the disability certificate submitted with the application; and (b)  provide the applicant with a notice indicating the amount, if any, that the insurer agrees to pay in respect of the specified benefit, the amount, if any, the insurer refuses to pay in respect of the specified benefit and the medical and any other reasons for the insurer’s decision.  O. Reg. 34/10, s. 36 (7). (8) Within 10 business days after delivering the notice under clause (7) (b), the insurer shall pay the amount, if any, that the insurer agrees to pay in respect of the specified benefit.  O. Reg. 34/10, s. 36 (8). (9) Every income replacement benefit, non-earner benefit or caregiver benefit shall be paid at least once every second week, subject to any prepayment of the benefit by the insurer.  O. Reg. 34/10, s. 36 (9).
Claim for Medical or Rehabilitation Benefits
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39.
 39. (1) This section applies to a claim for a medical or rehabilitation benefit or an application for approval of an assessment or examination under section 38 if the insurer gives the insured person a notice informing the insured person that the insurer will pay the expenses without the submission of a treatment and assessment plan under that section.  O. Reg. 34/10, s. 39 (1). (2) If the insurer gives the insured person a notice under subsection (1), (a)  the notice must describe the expenses that the insurer will pay without the submission of a treatment and assessment plan and shall specify, (i)  the types of expenses, (ii)  any restrictions on the amount of the expenses, and (iii)  any restrictions on when the expenses are to be incurred; (b)  the insurer shall comply with the requirements set out in any applicable Guideline if the notice is given in connection with a proposal, recommendation or suggestion that the insured person receive goods or services from a person named by the insurer; (c)  the insurer shall pay expenses described in the notice within 30 days after receiving an invoice for them; and (d)  the insurer shall, if there is a dispute described in subsection 280 (1) of the Act about whether for the purposes of subsection 15 (1) or 16 (3) an expense described in the notice is reasonable or necessary, or whether for the purposes of clause 15 (1) (h) or 16 (3) (l) an expense described in the notice is essential, pay the expense pending resolution of the dispute. O. Reg. 34/10, s. 39 (2); O. Reg. 44/16, s. 3. Claim for Medical or Rehabilitation Benefits to Which Minor Injury Guideline Applies
Claim for Medical or Rehabilitation Benefits to Which Minor Injury Guideline Applies
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41.
 41. (1) This section applies to a claim for medical or rehabilitation benefits under section 40 in respect of a minor injury, (a)  if the insurer gives the insured person a notice informing the insured person that the insurer offers to pay for the goods and services described in the Minor Injury Guideline without the submission of a treatment confirmation form; and (b)  if the insured person accepts the insurer’s offer and does not submit a treatment confirmation form in accordance with section 40 or a treatment and assessment plan in accordance with section 38 after receiving the notice described in clause (a).  O. Reg. 34/10, s. 41 (1). (2) If this section applies, the following rules apply: 1.  If the notice is given in connection with a proposal, recommendation or suggestion that the insured person receive goods or services from a person named by the insurer, the insurer shall also comply with any applicable Guideline. 2.  After the insured person submits an application under section 32 to the insurer, the insurer shall pay the expenses described in the notice within 30 days after receiving an invoice for them.  O. Reg. 34/10, s. 41 (2). Claim for Attendant Care Benefits
Claim for Attendant Care Benefits
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Other Types of Benefits
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43.
 43. (1) If a person is entitled to a death benefit, a funeral benefit or a benefit under Part IV, the insurer shall pay the benefit within 30 days after the insurer receives an application for the benefit.  O. Reg. 34/10, s. 43 (1). (2) If the insurer refuses to pay a benefit referred to in subsection (1), the insurer shall give the person a notice of the refusal and the medical and any other reasons for the refusal within 30 days after the insurer receives the application for the benefit.  O. Reg. 34/10, s. 43 (2). (3) In the case of a benefit for housekeeping and home maintenance services under section 23, subsections (1) and (2) are subject to sections 36 and 37.  O. Reg. 34/10, s. 43 (3). Additional Matters
Additional Matters
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45.1
 45.1 If an insured person who is under 18 years of age at the time of the accident sustains a traumatic brain injury that meets the criteria in subparagraph 5 i or 5 ii of subsection 3.1 (1) and that was caused by an accident that occurs on or after June 1, 2016, the person may submit an application under subsection 45 (1) and subsections 45 (2) to (5) do not apply, and the impairment is deemed to be a catastrophic impairment for the purposes of subsection 45 (6). O. Reg. 251/15, s. 18.
46.
 46. (1) This section applies if an insurer intends to refer an insured person to a person with whom the insurer has a potential conflict of interest and the referral is for the purpose of, (a)  the insured person obtaining any goods or services referred to in section 15 or 16 from the person recommended by the insurer; or (b)  the insured person being examined or assessed, other than under section 44, by the person recommended by the insurer.  O. Reg. 34/10, s. 46 (1). (2) The insurer shall not refer the insured person to the person unless the insurer has first given the insured person a notice that satisfies the following and the insured person gives a written consent to obtain the goods or services from or be examined or assessed by the person: 1.  The notice must specify the nature of the relationship between the insurer and the person, including the terms of remuneration of the person. 2.  The notice must specify the nature, amount and duration, if applicable, of the goods or services or the assessment or examination. 3.  The notice must inform the insured person that he or she is free to decline the proposed referral, or to revoke any consent given at any time, and that doing so will not prejudice or adversely affect the insured person’s entitlement to benefits. 4.  The notice must inform the insured person that he or she is free to choose from whom the insured person prefers to receive the goods and services, or by whom the insured person prefers to be assessed or examined, in accordance with this Regulation, and that doing so will not prejudice or adversely affect the insured person’s entitlement to benefits under this Regulation. 5.  The notice must inform the insured person of his or her rights and responsibilities with respect to the goods, services, assessments and examinations.  O. Reg. 34/10, s. 46 (2). (3) In this section, an insurer is deemed to have a potential conflict of interest with a person if, (a)  the insurer may receive a financial benefit, directly or indirectly, as a result of the provision of goods or services by, on behalf of, or under the authority or supervision of the person; or (b)  goods or services will be provided by, on behalf of, or under the authority or supervision of the person, (i)  pursuant to a subsisting arrangement with the insurer under which goods or services referred to in this Regulation are or will be provided at the insurer’s expense, or (ii)  as a result of the insurer’s referral, recommendation or suggestion of the person to the insured person.  O. Reg. 34/10, s. 46 (3). Part Ix   Payment of Benefits
PART IX PAYMENT OF BENEFITS
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46.1
 46.1 In this Part, “provider” means, (a)  a person who submits an invoice to an insured person or insurer for payment under this Regulation for goods or services, whether the goods or services were provided by the person or by another person, and (b)  a person, other than the person who submits the invoice described in clause (a), who provided any of the goods or services referred to in the invoice.  O. Reg. 194/11, s. 2.
46.2
 46.2 (1) An insurer may request any of the following information from a provider: 1.  Any information required to assist the insurer, acting reasonably, to determine its liability for the payment, including access to inspect and copy the originals of any treatment confirmation form, treatment and assessment plan, assessment of attendant care needs and other documents giving rise to the claim for payment. 2.  A statutory declaration as to the circumstances that gave rise to the invoice, including particulars of the goods and services provided. 3.  In the case of a provider described in clause (a) of the definition of “provider” in section 46.1, i.  the name and full municipal business address of the provider and of every provider described in clause (b) of that definition, and ii.  proof of the provider’s identity and of the identities of every provider described in clause (b) of that definition.  O. Reg. 194/11, s. 2. (2) The provider shall give the insurer the information requested under subsection (1) within 10 business days after receiving the request.  O. Reg. 194/11, s. 2. (3) For the purpose of section 51, the amount payable by an insurer under an invoice is not overdue and no interest accrues on it during any period during which a provider fails to comply with subsection (2).  O. Reg. 194/11, s. 2.
46.3
 46.3 (1) An insurer may request any of the following information from an insured person who submits an invoice to the insurer for payment for goods or services under this Regulation, or from an insured person on whose behalf such an invoice is submitted: 1.  Confirmation in writing that the goods or services were provided to the insured person. 2.  A statutory declaration as to the circumstances that gave rise to the invoice, including particulars as to when, where and by whom the goods or services were provided. O. Reg. 14/13, s. 6. (2) The insured person shall give the insurer the information requested under subsection (1) within 10 business days after receiving the request. O. Reg. 14/13, s. 6. (3) For the purpose of section 51, the amount payable by an insurer under an invoice is not overdue and no interest accrues on it during any period during which an insured person fails to comply with subsection (2). O. Reg. 14/13, s. 6.
47.
 47. (1) The insurer may deduct the following amounts from the amount payable to an insured person as an income replacement or non-earner benefit under this Regulation: 1.  Any temporary disability benefits being received by the insured person in respect of a period following the accident and in respect of an impairment that occurred before the accident. 2.  Any other periodic benefit being received by the insured person in respect of a period following the accident and in respect of an impairment that occurred before the accident, if the insured person was receiving that other periodic benefit at the time he or she first qualified for the income replacement or non-earner benefit and, at that time, the other periodic benefit was a temporary disability benefit.  O. Reg. 34/10, s. 47 (1). (2) Payment of a medical, rehabilitation or attendant care benefit or a benefit under Part IV is not required for that portion of an expense for which payment is reasonably available to the insured person under any insurance plan or law or under any other plan or law.  O. Reg. 34/10, s. 47 (2). (3) In this section, “temporary disability benefit” means, (a)  an income replacement or non-earner benefit paid under this Regulation or the Old Regulation, unless the benefit is paid more than 104 weeks after the onset of the disability, (b)  a caregiver benefit paid under this Regulation or the Old Regulation, (c)  benefits paid under Part III or IV or section 32 of Ontario Regulation 776/93, (d)  benefits paid under section 37, subsection 43 (9) or subsection 147 (2) of the pre-1997 Act, as defined in Part IX of the Workplace Safety and Insurance Act, 1997, in respect of injuries that occurred before January 1, 1998, including benefits paid under those provisions as those provisions are deemed to have been amended by Part IX of the Workplace Safety and Insurance Act, 1997, (e)  benefits paid under subsection 43 (3) of the Workplace Safety and Insurance Act, 1997
in respect of injuries that occurred after December 31, 1997, or (f)  any other periodic temporary benefit paid under an income continuation benefit plan or law, other than, (i)  benefits under the Employment Insurance Act (Canada), (ii)  a non-earner benefit paid under this Regulation or the Old Regulation more than 104 weeks after the onset of the disability, (iii)  benefits paid under Part V of Ontario Regulation 776/93 for more than 104 weeks, (iv)  benefits paid under Part IV of Regulation 672 of the Revised Regulations of Ontario, 1990 for more than 156 weeks, or (v)  benefits paid under Part II of Subsection 2 of Schedule C to the Insurance Act as it existed before June 22, 1990 that have been paid for more than 104 weeks.  O. Reg. 34/10, s. 47 (3).
48.
 48. (1) An insurer shall pay a benefit under this Regulation, (a)  by mailing or delivering a cheque payable to the person entitled to the benefit to the address where the person ordinarily resides; or (b)  with the consent of the person entitled to the benefit, by electronic funds transfer to an account in the name of the person.  O. Reg. 34/10, s. 48 (1). (2) Despite subsection (1), (a)  an insurer may arrange to be invoiced directly and to pay directly for goods or services provided in respect of an insured person; (b)  an insurer may pay a benefit into court under section 271 of the Act; or (c)  if the person entitled to the benefit has so directed in writing, an insurer shall pay the benefit directly to the person who submitted an invoice in respect of the benefit to a central processing agency in accordance with section 49.  O. Reg. 34/10, s. 48 (2); O. Reg. 370/10, s. 2.