42.1 (1) In this section, “original provider” means, in respect of an insured person, the member of a health profession who, in accordance with this Regulation, approved the treatment plan, prepared the assessment of attendant care needs, completed the disability certificate or prepared the application under section 40, as applicable, that was submitted to the insurer with respect to the insured person.  O. Reg. 546/05, s. 21. (2) This section applies in respect of an insured person if the following conditions are satisfied: 1.  An examination of the insured person was conducted under section 42 and the insurer gave to the insured person a copy of the report of the examination and the insurer’s determination. 2.  The insurer’s determination is, i.  that the insured person is not entitled to benefits, if the examination related to a claim for benefits, or ii.  that the insured person does not have a catastrophic impairment, if the examination related to an application under section 40. 3.  The examination under section 42 was not related to, i.  a claim for ancillary goods or services referred to in section 37.2, or ii.  an application under section 38.2 for approval for an assessment or examination. 4.  The examination under section 42 was not for the purposes of assisting the insurer determine if the insured person has an impairment to which a Pre-approved Framework Guideline applies. 5.  If the examination under section 42 related to a claim for a specified benefit under section 35, no assessment or examination relating to that benefit has been conducted previously under this section. 6.  If the examination under section 42 related to a claim for an attendant care benefits under section 39, no assessment or examination relating to that benefit has been conducted under this section within the previous 12 months. 7.  The examination under section 42 was not an examination to which subsection 42 (6) applied.  O. Reg. 546/05, s. 21. (3) The insurer shall pay fees in accordance with this section for an assessment or examination of the insured person and for the preparation of a report of the assessment or examination if the following conditions are satisfied: 1.  The assessment or examination and the report of the assessment or examination are limited to the portions of the report of the examination under section 42 with which the insured person does not agree and that are relevant to the denial of the claim or application. 2.  The assessment or examination is conducted by one or more members of a health profession who are authorized under this section to conduct the assessment or examination. 3.  If the insured person has sustained a catastrophic impairment or the examination under section 42 relates to whether the insured person has sustained a catastrophic impairment, the assessment or examination under this section is conducted and the report provided to the insurer not more than 80 business days after the day the insurer gave the insured person notice of its determination. 4.  If the insured person has not sustained a catastrophic impairment and the examination under section 42 does not relate to whether the insured person has sustained a catastrophic impairment, the assessment or examination is conducted and the report is provided to the insurer not more than 40 business days after the day the insurer gave the insured person notice of its determination.  O. Reg. 546/05, s. 21. (4) Subject to paragraph 2 of subsection (3) and subsections (5) and (6), an assessment or examination under this section must be conducted by the original provider or, if the insured person had more than one original provider, the original provider designated by the insured person.  O. Reg. 546/05, s. 21. (5) The assessment or examination under this section may be conducted by any person who is a member of any health profession if, (a)  the original provider is not a member of the same health profession as the person who conducted the examination under section 42; or (b)  the original provider is a member of the same health profession as the person who conducted the examination under section 42, but is not legally authorized to practise in the same specialty.  O. Reg. 546/05, s. 21. (6) If members of two or more health professions conducted the examination under section 42, the assessment or examination under this section may be conducted by one or more persons other than the original provider.  O. Reg. 546/05, s. 21. (7) The assessment or examination under this section shall be limited to an examination of the material provided under subsection 42 (10) to the person who conducted the examination under section 42 if, (a)  the examination under section 42 was conducted by a person who, (i)  is a member of the same health profession as the original provider, and (ii)  is legally authorized to practise in the same specialty as the original provider, if the original provider is legally authorized to practise in a specialty; (b)  the examination under section 42 was limited to an examination of the material provided under subsection 42 (10) to the person who conducted that examination; or (c)  the assessment or examination relates to a claim for medical benefits or rehabilitation benefits and an assessment or examination of the insured person with respect to the same accident has been conducted under this section within the previous 12 months.  O. Reg. 546/05, s. 21. (8) If the insured person does not have a catastrophic impairment and the assessment or examination under this section does not relate to whether the insured person has a catastrophic impairment, the total amount payable for an assessment or examination under this section, for the preparation of the report of the assessment or examination and for any related expenses permitted under section 24 shall not exceed the amount determined as follows: 1.  If the assessment or examination is limited to, or required by this section to be limited to, an examination of the material provided under subsection 42 (10), the maximum amount payable is $450. 2.  If the assessment or examination is not limited to nor required by this section to be limited to an examination of the material provided under subsection 42 (10), the maximum amount payable is, i.  $900 if the assessment or examination is conducted by one or more members of a health profession and at least one of them is a physician who is legally authorized to practise in a medical specialty other than family medicine, or ii.  $775 if the assessment or examination is conducted by one or more members of a health profession and none of them are physicians described in subparagraph i.  O. Reg. 546/05, s. 21. (9) Amounts payable under this section shall be paid by the insurer within 30 days after receipt of an invoice for the amounts.  O. Reg. 546/05, s. 21. (10) An assessment or examination under this section shall be used only for the purposes of assisting in the resolution of a dispute described in subsection 280 (1) of the Act and the insurer is not required as a result of receiving the report of the assessment or examination to allow any application or pay any benefit that it otherwise would not have allowed or paid.  O. Reg. 546/05, s. 21; O. Reg. 45/16, s. 4. Designated Assessments