42. (1) For the purposes of assisting an insurer determine if an insured person is or continues to be entitled to a benefit under this Regulation for which an application is made, an insurer may, as often as is reasonably necessary, require an insured person to be examined under this section by one or more persons chosen by the insurer who are members of a health profession or are social workers or who have expertise in vocational rehabilitation.  O. Reg. 546/05, s. 21. (2) Subsection (1) does not apply with respect to, (a)  a benefit to which section 37.1 applies, other than an amount claimed for ancillary goods or services referred to in section 37.2; or (b)  a funeral benefit or death benefit.  O. Reg. 546/05, s. 21. (3) Subject to subsection (7), each of the following examinations under this section shall be limited to an examination of material provided under subsection (10) in respect of the insured person without requiring the attendance of the insured person: 1.  An examination for the purposes of section 37.2 to assist the insurer in determining whether to pay for ancillary goods or services claimed by the insured person. 2.  An examination after an application is made under section 38 to assist the insurer in determining if the insured person has an impairment to which a Pre-approved Framework Guideline applies. 3.  An examination for the purposes of section 38 to assist the insurer in determining whether to pay for goods or services contemplated by a treatment plan if the goods and services are substantially similar to goods or services the insurer previously refused to pay for when they were included in a previous treatment plan submitted to the insurer on behalf of the insured person in respect of the same accident. 4.  An examination for the purposes of section 38.2 relating to an application for approval of an assessment or examination. 5.  An examination for the purposes of section 40 that relates only to the issue of whether the insured person has a brain impairment that results in a score of 9 or less on the Glasgow Coma Scale referred to in subclause 2 (1.2) (e) (i).  O. Reg. 546/05, s. 21. (4) Whenever the insurer requires an insured person to be examined under this section, the insurer shall arrange for the examination at its expense and shall give the insured person a notice setting out, (a)  the reasons for the examination; (b)  the type of examination that will be conducted and whether the attendance of the insured person is required during the examination; (c)  the name of the person or persons who will conduct the examination, the regulated health professions to which they belong and their titles and designations indicating their specialization, if any, in their professions; and (d)  if the attendance of the insured person is required at the examination, the day, time and location of the examination and, if the examination will require more than one day, the same information for the subsequent days.  O. Reg. 546/05, s. 21. (5) If the insurer has already notified the insured person under this Regulation that the insurer requires the insured person to be examined under this section, the insurer shall give the notice required under subsection (4), (a)  not more than two business days after the previous notice was given, if the attendance of the insured person is not required at the examination, unless the examination is for the purposes of assisting the insurer determine if the insured person has a catastrophic impairment; or (b)  not more than five business days after the previous notice was given and, unless the insured person and the insurer mutually agree otherwise, not less than five business days before the examination, if the attendance of the insured person is required at the examination or if the examination is for the purposes of assisting the insurer determine if the insured person has a catastrophic impairment.  O. Reg. 546/05, s. 21. (6) If the insurer is not authorized under another section of this Regulation to give the insured person notice that the insurer requires the insured person to be examined under this section, the insurer shall give the insured person the notice required under subsection (4) not less than five business days before the examination, unless the insured person and insurer mutually agree otherwise.  O. Reg. 546/05, s. 21. (7) If a notice under subsection (4) indicates that the attendance of the insured person is not required for the examination and it is subsequently determined by the person conducting the examination that the insured person should be in attendance and personally examined, the insurer shall give a notice to the insured person within two business days after the day the notice described in subsection (4) is given and at least five business days before the examination, (a)  notifying the insured person of the change in the type of examination; (b)  requiring the attendance of the insured person at the examination; and (c)  setting out the day, time and location of the examination and, if the examination will require more than one day, setting out the same information for the subsequent days.  O. Reg. 546/05, s. 21. (8) A notice under subsection (4) or (7) may be verbal if a written confirmation is given as soon as practicable afterwards.  O. Reg. 546/05, s. 21. (9) The following applies if the attendance of the insured person is required at an examination: 1.  The insurer shall make reasonable efforts to schedule the examination for a day and time that are convenient for the insured person. 2.  Subject to paragraph 3, the examination must be conducted, unless the insured person otherwise consents, at a location that is not more than, i.  30 kilometres from the insured person’s residence, if the residence is in the City of Toronto or in The Regional Municipality of Durham, The Regional Municipality of Halton, The Regional Municipality of Peel or The Regional Municipality of York, or ii.  50 kilometres from the insured person’s residence, if the residence is not in a municipality described in subparagraph i. 3.  If, after taking reasonable steps, the insurer is unable to arrange for a qualified person to conduct the examination at a location within the distance required under subparagraph 2 i or ii, as applicable, the insurer may arrange for the examination to be conducted by a qualified person at a location that is reasonable in the circumstances.  O. Reg. 546/05, s. 21. (10) For the purposes of the examination, (a)  the insured person and the insurer shall, within five business days after the day the notice of the examination under subsection (4) or (7) is received by the insured person, provide to the person or persons conducting the examination all reasonably available information and documents that are relevant or necessary for the review of the insured person’s medical condition; and (b)  if the attendance of the insured person is required at the examination, the insured person shall attend the examination and submit to all reasonable physical, psychological, mental and functional examinations requested by the person or persons conducting the examination.  O. Reg. 546/05, s. 21. (11) Subject to subsection (12), if the insured person complies with subsection (10), the person or persons conducting the examination shall complete the examination, prepare a report of their findings and provide a copy of the report to the insurer in accordance with the following: 1.  If the attendance of the insured person was not required for the examination, the examination must be completed and a copy of the report provided to the insurer, i.  not more than 10 business days after the day the notice of the examination under subsection (4) was given to the insured person, if the examination relates to whether the insured person has a catastrophic impairment, or ii.  not more than five business days after the day the notice of the examination under subsection (4) was given to the insured person, in any other case. 2.  If the attendance of the insured person was required at the examination and the examination relates to whether the insured person has sustained a catastrophic impairment or, if the insured person has sustained a catastrophic impairment, relates to whether the insured person is entitled to medical benefits, rehabilitation benefits, specified benefits under section 35 or attendant care benefits, i.  the examination must be completed not more than 30 business days after the day the notice relating to the examination was given under subsection (4) or, if a notice was given under subsection (7), 30 business days after the day that notice was given, and ii.  a copy of the report of the examination must be given to the insurer not later than 10 business days after the day the examination was completed. 3.  If the attendance of the insured person was required at the examination and paragraph 2 does not apply, i.  the examination must be completed not more than 10 business days after the day the notice relating to the examination was given under subsection (4) or, if a notice was given under subsection (7), 10 business days after the day that notice was given, and ii.  a copy of the report of the examination must be given to the insurer not later than 10 business days after the day the examination was completed.  O. Reg. 546/05, s. 21. (12) If an insured person who failed or refused to comply with subsection (10) subsequently complies, the following rules apply: 1.  If the attendance of the insured person was not required for the examination, the examination must be completed and a copy of the report provided to the insurer, i.  not more than 10 business days after the day the material required under subsection (10) was provided, if the examination relates to whether the insured person has a catastrophic impairment, or ii.  not more than five business days after the day the material required under subsection (10) was provided in any other case. 2.  If the attendance of the insured person was required for the examination, a copy of the report of the examination must be given to the insurer not later than 10 business days after the day the examination was completed.  O. Reg. 546/05, s. 21. (13) If the examination relates to a claim for attendant care benefits, the report of the examination must include an assessment of attendant care needs.  O. Reg. 546/05, s. 21. Assessment or Examination after Denial of Benefits