jswizzle3737/ontario_laws_and_regs huggingface dataset:
1. This Regulation may be cited as the Statutory Accident Benefits Schedule — Accidents on or after November 1, 1996.  O. Reg. 462/96, s. 2. Definitions and Interpretation
4. (1) The insurer shall pay an insured person who sustains an impairment as a result of an accident an income replacement benefit if the insured person meets any of the following qualifications: 1.  The insured person 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. 2.  The insured person, i.  was not employed at the time of the accident, ii.  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, iii.  was 16 years of age or more or was excused from attendance at school under the Education Act at the time of the accident, and iv.  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. 3.  The insured person, i.  was entitled at the time of the accident to start work within one year under a legitimate contract of employment that was made before the accident and that is evidenced in writing, and ii.  as a result of and within 104 weeks after the accident, suffers a substantial inability to perform the essential tasks of the employment he or she was entitled to start under the contract.  O. Reg. 403/96, s. 4. (2) Despite subsection (1), paragraph 3 of that subsection applies only if the accident occurs before April 15, 2004.  O. Reg. 458/03, s. 2. Period of Benefit
5. (1) Subject to subsection (2), an income replacement benefit is payable during the period that the insured person suffers a substantial inability to perform the essential tasks of the employment in respect of which he or she qualifies for the benefit under section 4.  O. Reg. 403/96, s. 5 (1). (2) The insurer is not required to pay an income replacement benefit, (a)  for the first week of the disability; (b)  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 engage in any employment for which he or she is reasonably suited by education, training or experience; (c)  in the case of an insured person who qualifies for the benefit under paragraph 3 of section 4, for the period before the day he or she would have been entitled under the contract to begin employment; (d)  for any period longer than 12 weeks after the accident, in the case of an insured person whose impairment is a Grade I whiplash-associated disorder that comes within a Pre-approved Framework Guideline, if the accident occurred after April 14, 2004; or (e)  for any period longer than 16 weeks after the accident, in the case of an insured person whose impairment is a Grade II whiplash-associated disorder that comes within a Pre-approved Framework Guideline, if the accident occurred after April 14, 2004.  O. Reg. 403/96, s. 5 (2); O. Reg. 458/03, s. 3; O. Reg. 295/07, s. 2. Amount of Benefit
7. (1) Despite subsections 6 (1) and (5), but subject to subsection 6 (2), the weekly amount of an income replacement benefit payable to a person shall be the lesser of the following amounts: 1.  The amount determined under subsections 6 (1) and (5), reduced by, i.  net weekly payments for loss of income that are being received by the person as a result of the accident under the laws of any jurisdiction or under any income continuation benefit plan, and ii.  net weekly payments for loss of income that are not being received by the person but are available to the person as a result of the accident under the laws of any jurisdiction or under any income continuation benefit plan, unless the person has applied to receive the payments for loss of income. 2.  The greater of the following amounts: i.  $400. ii.  If the optional income replacement benefit referred to in section 27 has been purchased and is applicable to the person, the amount fixed by the optional benefit.  O. Reg. 403/96, s. 7 (1); O. Reg. 462/96, s. 4; O. Reg. 281/03, s. 2 (1, 2). (2) For the purposes of paragraph 1 of subsection (1), the amount determined under subsections 6 (1) and (5) shall not be reduced by, (a)  benefits under the Employment Insurance Act (Canada) that are being received by or are available to the person; (b)  payments under a sick leave plan that are not being received by the person but are available to the person; or (c)  payments under a workers’ compensation law or plan that are not being received by the person and to which the person is not entitled because the person has elected under the workers’ compensation law or plan to bring an action.  O. Reg. 403/96, s. 7 (2); O. Reg. 281/03, s. 2 (3). (3) For the purpose of this section, net weekly payments for loss of income shall be determined by subtracting from the gross weekly amount of payments for loss of income the income tax payable by the person under the Income Tax Act
(Canada) and the Income Tax Act (Ontario) on the gross weekly amount of payments for loss of income.  O. Reg. 403/96, s. 7 (3). (4) For the purpose of subsection (3), the person whose net weekly payments for loss of income are to be determined shall be deemed to be a resident of Ontario.  O. Reg. 403/96, s. 7 (4). Gross Income Calculations
9. (1) Despite sections 6 and 7, if a person is receiving an income replacement benefit immediately before attaining 65 years of age, the weekly amount of the benefit shall be adjusted, on the later of the date the person attains 65 years of age and the second anniversary of the date the person began receiving the benefit, to the amount determined in accordance with the following formula: A = B × 0.02 × C where, A =  the amount to which the weekly amount of the income replacement benefit shall be adjusted, B =  the weekly amount of the income replacement benefit that the person was entitled to receive immediately before the adjustment, including any additions required by subsection 6 (5) but without making any deductions permitted by subsection 6 (2), C =  the lesser of, i.  35, and ii.  the number of years during which the person qualified for the income replacement benefit before the adjustment is made. O. Reg. 403/96, s. 9 (1). (2) An income replacement benefit that has been adjusted under subsection (1) is payable until the person dies.  O. Reg. 403/96, s. 9 (2). (3) Section 5 and subsections 6 (2) to (6) do not apply to an income replacement benefit that has been adjusted under subsection (1).  O. Reg. 403/96, s. 9 (3). Entitlement Arising after Age 65
10. (1) Despite sections 6 and 7, if a person becomes entitled to receive an income replacement benefit after attaining 65 years of age, the weekly amount of the benefit shall be the amount determined under section 7 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 

  208 weeks or more   0.0 O. Reg. 403/96, s. 10 (1). (2) An income replacement benefit is no longer payable to a person to whom subsection (1) applies if more than 208 weeks have elapsed since the person became entitled to the benefit.  O. Reg. 403/96, s. 10 (2). (3) Subsections 6 (2) to (6) do not apply to the income replacement benefit paid to a person to whom subsection (1) applies.  O. Reg. 403/96, s. 10 (3).
10.1 The age distinctions in sections 9 and 10 apply despite the Human Rights Code.  O. Reg. 536/06, s. 1. Temporary Return to Employment
11. A person receiving an income replacement benefit may return to or start an employment at any time during the 104 weeks following the onset of the disability in respect of which the benefit is paid without affecting his or her entitlement to resume receiving benefits under this Part if, as a result of the accident, he or she is unable to continue in the employment.  O. Reg. 403/96, s. 11. PART III   NON-EARNER BENEFIT
13. (1) The insurer shall pay an insured person who sustains an impairment as a result of an accident a caregiver benefit if the insured person meets all of the following qualifications: 1.  At the time of the accident, i.  the insured person was residing with a person in need of care, and ii.  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. 2.  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 engaged at the time of the accident.  O. Reg. 403/96, 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.  O. Reg. 403/96, s. 13 (2). (3) The amount of the caregiver benefit shall not exceed, (a)  for the first person in need of care, (i)  $250 per week, or (ii)  if the optional caregiver and dependant care benefit referred to in section 27 has been purchased and is applicable to the insured person, the amount fixed by the optional benefit; and (b)  for each additional person in need of care, (i)  $50 per week, or (ii)  if the optional caregiver and dependant care benefit referred to in section 27 has been purchased and is applicable to the insured person, the amount fixed by the optional benefit.  O. Reg. 403/96, s. 13 (3). (4) The insurer is not required to pay a caregiver benefit 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. 403/96, s. 13 (4). PART V   MEDICAL, REHABILITATION AND ATTENDANT CARE BENEFITS Medical Benefit
14. (1) The insurer shall pay an insured person who sustains an impairment as a result of an accident a medical benefit.  O. Reg. 403/96, s. 14 (1). (2) The medical benefit 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; (h)  other goods and services of a medical nature that the insured person requires.  O. Reg. 403/96, s. 14 (2). (3) The insurer is not liable to pay a medical benefit for goods or services that are experimental in nature.  O. Reg. 403/96, s. 14 (3). (4) The insurer is not liable to pay a medical benefit for expenses related to professional services described in clause (2) (a), (b) or (h) rendered to an insured person that exceed the maximum rate or amount of expenses established under the Guidelines applicable to the claim.  O. Reg. 281/03, s. 3. (4.1) If the Guidelines applicable to the claim establish a range of rates or amounts for expenses related to professional services rendered to an insured person, (a)  the highest rate or amount in the range shall be deemed, for the purposes of subsection (4), to be the maximum rate or amount established under the Guidelines
applicable to the claim; and (b)  an insurer that is liable to pay a medical benefit for expenses related to the services described in clause (2) (a), (b) or (h) shall not pay less than the lowest amount or rate in the range unless the insured person’s claim is for less than the lowest amount or rate in the range.  O. Reg. 281/03, s. 3. (5) Subject to subsection (6), the insurer is not liable to pay a medical benefit under clause (2) (g) for expenses related to transportation unless the expenses are authorized by, and are calculated by applying the rates set out in, the Transportation Expense Guidelines published in The Ontario Gazette by the Ontario Insurance Commission or Financial Services Commission of Ontario, as they may be amended from time to time.  O. Reg. 403/96, s. 14 (5); O. Reg. 303/98, s. 1 (2). (6) The insurer is not liable to pay a medical benefit under clause (2) (g) for expenses related to, (a)  the first 50 kilometres of transportation in the insured person’s automobile to and from a treatment session if the accident occurred before April 15, 2004; or (b)  the first 50 kilometres of transportation to and from a treatment session if the accident occurred after April 14, 2004, unless the insured person sustained a catastrophic impairment as a result of the accident.  O. Reg. 458/03, s. 4. Rehabilitation Benefit
16. (1) The insurer shall pay an insured person who sustains an impairment as a result of an accident an attendant care benefit.  O. Reg. 403/96, s. 16 (1). (1.1) Despite subsection (1), if the accident occurred after April 14, 2004, no attendant care benefit is payable to an insured person whose impairment is a Grade I or Grade II whiplash-associated disorder that comes within a Pre-approved Framework Guideline.  O. Reg. 295/07, s. 3. (2) The attendant care benefit 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)  services provided by an aide or attendant; or (b)  services provided by a long-term care facility, including a nursing home, home for the aged or chronic care hospital.  O. Reg. 403/96, s. 16 (2). (3) Subsection (2) does not apply to expenses for which payment may be obtained under clause 14 (2) (g), 15 (5) (k) or subsection 24 (1.6).  O. Reg. 403/96, s. 16 (3); O. Reg. 533/06, s. 2. (4) The monthly amount payable by the attendant care benefit shall be determined in accordance with Form 1.  O. Reg. 403/96, s. 16 (4). (5) The amount of the attendant care benefit payable in respect of an insured person shall not exceed the amount determined under the following rules: 1.  If the accident occurred before October 1, 2003, the amount of the attendant care benefit payable in respect of the insured person shall not exceed, i.  $3,000 per month, if the insured person did not sustain a catastrophic impairment as a result of the accident, or ii.  $6,000 per month, if the insured person sustained a catastrophic impairment as a result of the accident. 2.  If the accident occurred on or after October 1, 2003 and the optional medical, rehabilitation and attendant care benefit referred to in section 27 has not been purchased and does not apply to the insured person, the amount of the attendant care benefit payable in respect of the insured person shall not exceed, i.  $3,000 per month, if the insured person did not sustain a catastrophic impairment as a result of the accident, or ii.  $6,000 per month, if the insured person sustained a catastrophic impairment as a result of the accident. 3.  If the accident occurred on or after October 1, 2003 and the optional medical, rehabilitation and attendant care benefit referred to in section 27 has been purchased and applies to the insured person, the amount of the attendant care benefit payable in respect of the insured person shall not exceed the monthly limit under subsection 27 (5).  O. Reg. 281/03, s. 5; O. Reg. 458/03, s. 6 (2). Case Manager Services
17. (1) The insurer shall pay 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 plan if, (a)  the insured person sustains a catastrophic impairment as a result of the accident; or (b)  the accident occurred on or after October 1, 2003 and the optional medical, rehabilitation and attendant care benefit referred to in section 27 has been purchased and applies to the insured person.  O. Reg. 281/03, s. 6. (2) The insurer is not liable under subsection (1) to pay expenses related to professional services rendered to an insured person that exceed the maximum rate or amount of expenses established under the Guidelines applicable to the claim.  O. Reg. 281/03, s. 6. (3) If the Guidelines applicable to the claim establish a range of rates or amounts for expenses related to professional services rendered to an insured person, (a)  the highest rate or amount in the range shall be deemed, for the purpose of subsection (2), to be the maximum rate or amount established under the Guidelines
applicable to the claim; and (b)  an insurer that is liable under subsection (1) to pay expenses related to the services rendered to the insured person shall not pay less than the lowest amount or rate in the range, unless the insured person’s claim is for less than the lowest amount or rate in the range.  O. Reg. 281/03, s. 6. Duration of Medical, Rehabilitation and Attendant Care Benefits
18. (1) No medical or rehabilitation benefit is payable for expenses incurred, (a)  more than 10 years after the accident, in the case of an insured person who was 15 years of age or more at the time of the accident; or (b)  after the insured person attains 25 years of age, in the case of an insured person who was less than 15 years of age at the time of the accident.  O. Reg. 403/96, s. 18 (1). (2) No attendant care benefit is payable for expenses incurred more than 104 weeks after the accident.  O. Reg. 403/96, s. 18 (2). (3) Subsections (1) and (2) do not apply in respect of an insured person who sustains a catastrophic impairment as a result of the accident.  O. Reg. 403/96, s. 18 (3). (4) Subsections (1) and (2) do not apply if the optional medical, rehabilitation and attendant care benefit referred to in section 27 has been purchased and is applicable to the insured person.  O. Reg. 403/96, s. 18 (4). Maximum Limits on Medical, Rehabilitation and Attendant Care Benefits
19. (1) The sum of the medical and rehabilitation benefits paid in respect of an insured person shall not exceed, for any one accident, (a)  $100,000; or (b)  if the insured person sustained a catastrophic impairment as a result of the accident, $1,000,000.  O. Reg. 403/96, s. 19 (1). (2) The amount of the attendant care benefit paid in respect of an insured person shall not exceed, for any one accident, (a)  $1,000,000, if the insured person sustained a catastrophic impairment as a result of the accident; (b)  nil, if the accident occurred after April 14, 2004 and the insured person’s impairment is a Grade I or Grade II whiplash-associated disorder that comes within a Pre-approved Framework Guideline; or (c)  $72,000 in any other case.  O. Reg. 458/03, s. 7; O. Reg. 295/07, s. 4. (3) If the optional medical, rehabilitation and attendant care benefit referred to in section 27 was purchased and applies to the insured person, the maximum limits fixed by the optional benefit apply and subsection (1) and clauses (2) (a) and (c) do not apply.  O. Reg. 458/03, s. 7. (4) For the purpose of subsection (1), the medical and rehabilitation benefits paid in respect of an insured person include any amount paid in respect of the insured person under section 17.  O. Reg. 403/96, s. 19 (4). PART VI   PAYMENT OF OTHER EXPENSES Lost Educational Expenses
20. (1) The insurer shall pay 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. 403/96, s. 20 (1). (2) The amount payable under this section shall not exceed $15,000.  O. Reg. 403/96, s. 20 (2). (2.1) The insurer may require a person who claims or is receiving benefits under this section to furnish a disability certificate as often as is reasonably necessary.  O. Reg. 546/05, s. 2. (2.2) 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. 546/05, s. 2. (2.3) If the person fails to comply with subsection (2.2), no amount is payable for lost educational expenses until the person furnishes the completed disability certificate.  O. Reg. 546/05, s. 2. (3) 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. 403/96, s. 20 (3). Expenses of Visitors
21. (1) If an insured person sustains an impairment as a result of an accident, the insurer shall pay for reasonable and necessary expenses incurred 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. 403/96, s. 21 (1); O. Reg. 114/00, s. 2; O. Reg. 314/05, s. 2. (2) No payment is required under this section for expenses incurred more than 104 weeks after the accident.  O. Reg. 403/96, s. 21 (2). (3) Subsection (2) does not apply if the insured person sustained a catastrophic impairment as a result of the accident.  O. Reg. 403/96, s. 21 (3). Housekeeping and Home Maintenance
22. (1) The insurer shall pay 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 an 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. 403/96, s. 22 (1). (2) The amount payable under this section shall not exceed $100 per week.  O. Reg. 403/96, s. 22 (2). (3) No payment is required under this section for expenses incurred more than 104 weeks after the onset of the disability.  O. Reg. 403/96, s. 22 (3). (4) Subsection (3) does not apply if the insured person sustained a catastrophic impairment as a result of the accident.  O. Reg. 403/96, s. 22 (4). Damage to Clothing, Glasses, Hearing Aids, etc.
23. The insurer shall pay for all reasonable expenses incurred by or on behalf of an insured person in repairing or replacing, (a)  clothing worn by the insured person at the time of an accident that was lost or damaged as a result of the accident; or (b)  prescription eyewear, dentures, hearing aids, prostheses and other medical or dental devices that were lost or damaged as a result of an accident.  O. Reg. 403/96, s. 23. Cost of Examinations
24.1 (1) The following conditions must be satisfied for the purposes of paragraph 9 of subsection 24 (1): 1.  The consulting fees must be charged by one of the following persons: i.  the health practitioner who prepared the disability certificate, if the examination relates to a claim in respect of which a disability certificate is required under this Regulation, ii.  the health practitioner who approved the treatment plan, if the examination relates to a claim for medical or rehabilitation benefits, iii.  the member of the health profession who prepared the assessment of attendant care needs, if the examination relates to an application under section 39, or iv.  the health practitioner who prepared the application, if the examination relates to an application under section 40 to assist the insurer determine whether the insured person has sustained a catastrophic impairment. 2.  The consultation must be arranged by mutual agreement of the person who is conducting or has conducted the examination under section 42 and the health practitioner or member of the health profession involved in the consultation. 3.  The fees must be reasonable and, subject to subsection (2), shall not exceed the amount ordinarily charged for a 30 minute professional consultation by telephone.  O. Reg. 546/05, s. 4. (2) If under a Guideline a maximum rate or amount for expenses is established that applies to the claim with respect to which the examination under section 42 and consultation relate and the payment of the fees for the consultation would result in the expenses exceeding this maximum rate or amount, only the portion of the fees for the consultation that would not result in the expenses for the claim exceeding the maximum rate or amount shall be paid.  O. Reg. 546/05, s. 4. PART VII   DEATH AND FUNERAL BENEFITS Death Benefit
26. (1) The insurer shall pay a funeral benefit in respect of an insured person who dies as a result of an accident.  O. Reg. 403/96, s. 26 (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 27 has been purchased and is applicable to the insured person, the amount fixed by the optional benefit.  O. Reg. 403/96, s. 26 (2). PART VIII   OPTIONAL BENEFITS Description of Optional Benefits
28. (1) The 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 meets the following qualifications: 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. 403/96, s. 28 (1). (2) No payment is required under this section in respect of an expense incurred after the insured person dies.  O. Reg. 403/96, s. 28 (2). (3) The amount payable under this section shall not exceed $75 per week for the first dependant and $25 per week for each additional dependant.  O. Reg. 403/96, s. 28 (3). (4) The total amount payable under this section shall not exceed $150 per week.  O. Reg. 403/96, s. 28 (4). Optional Indexation Benefit
31. (1) 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. 403/96, s. 31 (1). (2) Subsection (1) does not apply to the time limits set out in section 51.  O. Reg. 403/96, s. 31 (2). Notice and Application for Benefits
32.1 (1) This section applies if, (a)  as a result of an accident, an insured person was admitted to a hospital or long-term care facility and is still in the hospital or facility or was discharged within the previous three days; (b)  the insured person may be entitled to medical benefits for an assistive device referred to in clause 14 (2) (f), rehabilitation benefits under clause 15 (5) (i) or attendant care benefits under section 16; and (c)  no application has yet been made for a benefit to which the insured person may be entitled as a result of the accident.  O. Reg. 546/05, s. 6. (2) At the insured person’s request or with his or her consent, the insurer may arrange for the insured person to be examined at the insurer’s expense for the purposes of assisting the insurer in determining if the insured person is entitled to receive a benefit described in clause (1) (b) that would assist the insured person after his or her discharge from the hospital or long-term care facility.  O. Reg. 546/05, s. 6. (3) An examination under this section shall be conducted by one or more members of one or more health professions who are chosen by the insurer.  O. Reg. 546/05, s. 6. (4) The insurer shall notify the insured person of the name of the person or persons who will conduct the examination and the day, time and place for the examination.  O. Reg. 546/05, s. 6. (5) The insurer shall, before the examination, obtain the written and signed consent of the insured person for the examination.  O. Reg. 546/05, s. 6. (6) The person or persons who conducted the examination shall, within five business days after conducting the examination, prepare a written report and, if applicable, an assessment of attendant care needs and provide a copy to, (a)  the insurer; (b)  the insured person; and (c)  if the insured person has a health practitioner, that health practitioner.  O. Reg. 546/05, s. 6. (7) An examination under this section is voluntary and any failure or refusal of an insured person to consent to an examination under this section does not affect any rights the insured person may have to apply for or receive benefits as a result of the accident.  O. Reg. 546/05, s. 6. (8) The report of an examination under this section shall not be relied on by an insurer in making a determination that an insured person is not entitled to a benefit under this Regulation.  O. Reg. 546/05, s. 6. Duty of Applicant to Provide Information
33. (1) A person applying for a benefit under this Regulation 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 person’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 person ordinarily resides. 4.  Proof of the person’s identity.  O. Reg. 403/96, s. 33 (1); O. Reg. 546/05, s. 7. (1.1) If requested by the insurer, a person who applies for a benefit under this Regulation as a result of an accident shall submit to an examination under oath, but is not required to, (a)  submit to more than one examination under oath in respect of matters relating to the same accident; or (b)  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. 281/03, s. 12 (1). (1.2) A person is entitled to be represented at his or her own expense at the examination under oath by such counsel or other representative of his or her choice as the law otherwise permits.  O. Reg. 281/03, s. 12 (1). (1.3) The insurer shall make reasonable efforts to schedule the examination under oath for a time and location that are convenient for the person and shall give the person reasonable advance notice of the following: 1.  The date and location of the examination. 2.  That the person is entitled to be represented in the manner described in subsection (1.2). 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 person’s entitlement to benefits.  O. Reg. 281/03, s. 12 (1). (1.4) The insurer shall limit the scope of the examination under oath to matters that are relevant to the person’s entitlement to benefits under this Regulation.  O. Reg. 281/03, s. 12 (1). (2) The insurer is not liable to pay a benefit in respect of any period during which the insured person failed to comply with subsection (1) or (1.1).  O. Reg. 281/03, s. 12 (2). (3) Subsection (2) does not apply in respect of a non-compliance with subsection (1.1) if, (a)  the insurer fails to comply with subsection (1.3) or (1.4); or (b)  the insurer interferes with the insured person’s right to be represented as described in subsection (1.2).  O. Reg. 281/03, s. 12 (2). (4) If an insured person who failed to comply with subsection (1) or (1.1) 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 insured person provides a reasonable explanation for the delay in complying with the subsection.  O. Reg. 281/03, s. 12 (2).
34. Revoked:  O. Reg. 546/05, s. 8. Income Replacement, Non-earner or Caregiver Benefits and Housekeeping or Home Maintenance Expenses
36. (1) Only one of the following benefits may be paid to a person in respect of a period of time: 1.  An income replacement benefit. 2.  A non-earner benefit. 3.  A caregiver benefit.  O. Reg. 403/96, s. 36 (1). (2) If a person’s application indicates that he or she may qualify for more than one of the benefits referred to in subsection (1), the insurer shall notify the person that he or she must elect within 30 days after receiving the notice which benefit he or she wishes to receive.  O. Reg. 403/96, s. 36 (2). (3) The insurer shall deliver the notice under subsection (2) within 10 business days after receiving the person’s application.  O. Reg. 403/96, s. 36 (3); O. Reg. 546/05, s. 10. Determination of Continuing Entitlement to Specified Benefits
37.2 (1) In this section, ancillary goods or services, in respect of an impairment to which a Pre-approved Framework Guideline applies, are goods or services for which the Guideline, (a)  requires the insurer’s approval; and (b)  permits a claim to be made in a treatment confirmation form under section 37.1.  O. Reg. 281/03, s. 15. (2) If a treatment confirmation form under section 37.1 includes a claim for ancillary goods or services, the insurer shall, (a)  include in the notice required under subsection 37.1 (5) a statement of which ancillary goods and services, if any, the insurer agrees to pay for; and (b)  notify the insured person that the insurer requires the insured person to be examined under section 42, if the insurer has not agreed to pay for all of the ancillary goods and services included in the claim.  O. Reg. 546/05, s. 13. (3) A notice referred to in clause (2) (b) must be given to the insured person within five business days after the day the insurer receives the treatment confirmation form.  O. Reg. 546/05, s. 13. (4) If the insurer fails to comply with the requirements of subsection 37.1 (5) or subsection (3) of this section within the time required under those subsections, the insurer shall pay for all ancillary goods and services delivered under the treatment confirmation form.  O. Reg. 546/05, s. 13. (5) Within five business days after receiving the report of an examination under section 42, the insurer shall give a copy of the report and the insurer’s determination with respect to payment for the ancillary goods and services to the insured person and the health practitioner who prepared the treatment confirmation form. O. Reg. 546/05, s. 13. (6) The determination of the insurer shall specify the ancillary goods and services the insurer agrees to pay for, the ancillary goods and services the insurer refuses to pay for and the reasons for the insurer’s decision.  O. Reg. 546/05, s. 13. (7) If an insured person fails or refuses to comply with subsection 42 (10), the insurer may make a determination that the insured person is not entitled to payment for the ancillary goods and services to which the examination relates.  O. Reg. 546/05, s. 13. (8) If an insured person subsequently complies with subsection 42 (10), the insurer shall reconsider the insured person’s claim and make a determination under this section.  O. Reg. 546/05, s. 13. (9) If the insurer fails to provide a copy of the report of the examination under section 42 or its determination in respect of the claim by the day determined in the following manner, the insurer shall pay for all ancillary goods and services provided in accordance with the treatment confirmation form: 1.  If the attendance of the insured person was not required for the examination under section 42, the day is the 10th business day after the day the material required under subsection 42 (10) was provided. 2.  If the attendance of the insured person was required for the examination, the day is the 15th business day after the day the examination was completed or was required under paragraph 2 or 3 of subsection 42 (11) to be completed.  O. Reg. 546/05, s. 13.
37.3 (1) This section applies to a claim for medical or rehabilitation benefits under section 37.1 or 37.2 in respect of an impairment that is asserted by the insurer to come within a Pre-approved Framework Guideline if the insurer gives the insured person a notice informing the insured person that the insurer will pay for the goods and services described in the Pre-approved Framework Guideline without the submission of a treatment confirmation form under either of those sections.  O. Reg. 533/06, s. 6. (2) If an insurer gives notice under subsection (1), the notice shall satisfy the following criteria: 1.  The notice must specify which Pre-approved Framework Guideline the insurer asserts to be applicable to the claimant’s impairment and confirm that the insurer will pay for goods and services under section 37.1 in accordance with the Pre-approved Framework Guideline without the submission of a treatment confirmation form under that section. 2.  The notice must describe the expenses for ancillary goods or services, if any, as referred to in section 37.2, that the insurer will pay without the submission of a treatment confirmation form 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 may be incurred. 3.  The notice must disclose any conflict of interest that the insurer has relating to any person who will provide goods or services to whom the insured person is referred by the insurer.  O. Reg. 533/06, s. 6. (3) If an insurer gives notice under subsection (1), (a)  the insurer shall, if the insured person has submitted an application under section 32 to the insurer, pay the expenses described in the notice within 30 days after receiving an invoice for them; and (b)  if there is a dispute under section 280 of the Act about whether, for the purpose of subsection 14 (2) or 15 (5), an expense described in the notice is reasonable or necessary, the insurer shall pay the expense pending resolution of the dispute. O. Reg. 533/06, s. 6; O. Reg. 45/16, s. 2. (4) An insured person who receives a notice under subsection (1) may, despite the notice, submit a treatment confirmation form in accordance with section 37.1 or a treatment plan in accordance with section 38, in which case this section shall not apply.  O. Reg. 533/06, s. 6. Medical and Rehabilitation Benefits
38.1 (1) This section applies to a claim for a medical or rehabilitation benefit 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 plan under that section.  O. Reg. 281/03, s. 17. (2) If the insurer gives the insured person a notice under subsection (1), (a)  the notice shall describe the expenses that the insurer will pay without the submission of a treatment 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 may be incurred; (b)  the insurer shall pay expenses described in the notice within 30 days after receiving an invoice for them; and (c)  if there is a dispute under section 280 of the Act about whether, for the purpose of subsection 14 (2) or 15 (5), an expense described in the notice is reasonable or necessary, the insurer shall pay the expense pending resolution of the dispute. O. Reg. 281/03, s. 17; O. Reg. 45/16, s. 3. (3) The insurer shall give the insured person a notice disclosing any conflict of interest that the insurer has relating to any person who will provide goods or services to whom the insured person is referred by the insurer.  O. Reg. 281/03, s. 17; O. Reg. 533/06, s. 8 (1). (4) Every member of a health profession and social worker who refers an insured person to another person to obtain goods or services in respect of which a medical or rehabilitation benefits will be paid by an insurer under this section shall give the insurer and the insured person written notice disclosing any conflict of interest the member of the health profession or social worker has relating to the provision of the goods or services.  O. Reg. 546/05, s. 15; O. Reg. 533/06, s. 8 (2). (5) If a conflict of interest is disclosed under subsection (4), the insurer may give the insured person a notice requiring the insured person to submit a treatment plan to the insurer under section 38 and, if a notice is given under this subsection, (a)  the insurer is relieved of any obligation under this section to pay expenses other than expenses incurred before the notice was given; (b)  subsections (1) to (4) do not apply; and (c)  the insured person may submit an application and treatment plan under section 38.  O. Reg. 281/03, s. 17. Application for Approval of an Assessment or Examination
38.3 (1) For the purposes of sections 37.1, 37.3, 38, 38.1 and 38.2, (a)  a person has a conflict of interest relating to the provision of goods or services if, (i)  the person or a related person may receive a financial benefit, directly or indirectly, as a result of the provision, by the related person or another person, of the goods or services, and (ii)  the person who may receive the financial benefit is not the employee of the person who will provide the goods or services and does not have a contract with the person who will provide the goods or services or under which goods or services of that kind are provided; and (b)  an insurer has a conflict of interest relating to the provision of goods or services to an insured person if, (i)  the insurer may receive a financial benefit, directly or indirectly, as a result of the provisions of the goods or services, or (ii)  the goods or services will be provided by a person 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.  O. Reg. 281/03, s. 17; O. Reg. 533/06, s. 10. (2) A related person, in respect of a person who is not a corporation, is an individual who is, (a)  the spouse of the person; (b)  connected with the person by blood relationship or adoption; or (c)  connected by blood relationship to the spouse of the person.  O. Reg. 281/03, s. 17; O. Reg. 314/05, s. 5. (3) For the purposes of subsection (2), (a)  persons are connected by blood relationship if one is the child or other descendant of the other or is the brother or sister of the other; and (b)  persons are connected by adoption if one has been adopted, either legally or in fact, as the child of the other or as a child of a person who is connected by blood relationship, otherwise than as brother or sister, to the other.  O. Reg. 281/03, s. 17. Attendant Care Benefits
41. (1) If a person is entitled to a death benefit, a funeral benefit or a benefit under Part VI, the insurer shall pay the benefit within 30 days after the insurer receives the application for the benefit.  O. Reg. 403/96, s. 41 (1). (2) If the insurer refuses to pay a benefit referred to in subsection (1), the insurer shall give the person notice of the reasons for the refusal within 30 days after the insurer receives the application for the benefit.  O. Reg. 403/96, s. 41 (2). (3) In the case of a benefit described in section 22, subsections (1) and (2) are subject to sections 35 and 37.  O. Reg. 546/05, s. 19. Transitional Rules — March 1, 2006
44. (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. 403/96, s. 44 (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 Insurance Act; or (c)  where 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 subsection 44.1 (1).  O. Reg. 403/96, s. 44 (2); O. Reg. 533/06, s. 11.
44.1 (1) Despite any other provision of this Regulation, if a benefit that would otherwise be payable by an insurer is payable in respect of an expense for goods or services specified in a Guideline issued for the purposes of this section, an insurer to whom the Guideline applies shall not pay the benefit unless an invoice for the expense, in the form approved by the Superintendent and including all of the information required by the form,  (a)  is delivered to the insurer, if neither of paragraph 2 or 3 of subsection 68 (3.2) applies; or (b)  is deemed to be received by the insurer under subsection 68 (3.3) or (3.4), if paragraph 2 or 3 of subsection 68 (3.2) applies.  O. Reg. 533/06, s. 12. (2) An insurer shall not waive the submission of an invoice for goods or services to which subsection (1) applies.  O. Reg. 533/06, s. 12. (3) If a Guideline issued for the purposes of subsection 68 (3.2) specifies that invoices are to be delivered to a central processing agency on behalf of insurers to whom the Guideline applies, every such insurer that receives an invoice that complies with subsection (1) shall report the following to the central processing agency in the manner and within the time required by the Guideline: 1.  The date or dates on which the goods or services referred to in the invoice were delivered or rendered. 2.  The names, addresses and professional college registration numbers, if applicable, of each provider of goods or services referred to in the invoice. 3.  Particulars of the goods or services referred to in the invoice. 4.  Particulars of the injury or injuries in respect of which the goods or services were delivered or rendered. 5.  The amount, if any, paid in respect of the goods or services referred to in the invoice by any person other than the insurer. 6.  The amount paid by the insurer in respect of the invoice. 7.  The amount paid by the insurer in respect of each separately described component of the invoice. 8.  The date on which a decision was made on payment or other disposition of the invoice. 9.  Any other disposition of the invoice. 10.  The information referred to in subsection 32 (2.1). 11.  Such additional information as may be specified in the Guideline, if the invoice is in respect of expenses described in a notice given by the insurer under subsection 37.3 (1) or 38.1 (1).  O. Reg. 533/06, s. 12. Explanation of Benefit Amounts
45. When a benefit is first paid or the amount of the benefit is subsequently changed, the insurer shall provide the insured person with a written explanation of how the amount of the benefit was determined.  O. Reg. 403/96, s. 45. Overdue Payments
46. (1) An amount payable in respect of a benefit is overdue if the insurer fails to pay the benefit within the time required under this Part.  O. Reg. 403/96, s. 46 (1). (2) If payment of a benefit under this Regulation is overdue, the insurer shall pay interest on the overdue amount for each day the amount is overdue from the date the amount became overdue at the rate of 2 per cent per month compounded monthly.  O. Reg. 403/96, s. 46 (2). Repayments to Insurer