Determination of Catastrophic Impairment

(1) An insured person who sustains impairment as a result of an accident may apply to the insurer for a determination of whether the impairment is a catastrophic impairment. O. Reg. 403/96, s. 40 (1).

(2) Within 30 days after receiving an application under subsection (1), the insurer shall give the insured person,

(a) a notice stating that the insurer has determined that the impairment is a catastrophic impairment; or

(b) a notice advising the insured person that the insurer requires the insured person to be examined under section 42 to assist the insurer in determining if the impairment is a catastrophic impairment. O. Reg. 546/05, s. 18.

(3) If an application is made under this section not more than 104 weeks after the accident and, immediately before the application was made, the insured person was receiving attendant care benefits,

(a) the insurer shall continue to pay attendant care benefits to the insured person during the period before the insurer makes a determination under this section; and

(b) the amount of the attendant care benefits for the period referred to in clause (a) shall be determined on the assumption that the insured person’s impairment is a catastrophic impairment. O. Reg. 546/05, s. 18.

(3.1) Revoked: O. Reg. 546/05, s. 18.

(4) 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 of whether the insured person’s impairment is a catastrophic impairment to the insured person and to the health practitioner who prepared the application under this section. O. Reg. 546/05, s. 18.

(5) The determination of the insurer shall specify the reasons for the insurer’s determination of whether the insured person’s impairment is a catastrophic impairment. O. Reg. 546/05, s. 18.

(6) If an insured person fails or refuses to comply with subsection 42 (10), the insurer,

(a) may make a determination that the insured person does not have a catastrophic impairment;

(b) may stop payment of any benefits that are payable only if the insured person has a catastrophic impairment; and

(c) may, in respect of the period after the insured person failed or refused to comply with subsection 42 (10) and before the insured person submits to the examination and provides the material required by subsection 42 (10), refuse to pay a benefit or expense that is payable only if the person has a catastrophic impairment. O. Reg. 546/05, s. 18.

(7) If an insured person subsequently complies with subsection 42 (10), the insurer shall,

(a) reconsider the application and make a determination under this section;

(b) subject to the determination, resume payment of benefits, if benefits were being paid before the examination; and

(c) pay all amounts, if any, that were withheld during the period of non-compliance, if the insurer determines that the insured person sustained a catastrophic impairment and the insured person provides not later than the 10th business day after the failure or refusal to comply, or as soon as practicable after that day, a reasonable explanation for not complying with subsection 42 (10). O. Reg. 546/05, s. 18.

(8) If the insurer fails to provide a copy of the report of the examination under section 42 or its determination in respect of the application by the day determined in the following manner, the insurer shall, for the period commencing on that day and ending on the day the insurer gives the insured person the report or determination, pay all amounts in respect of benefits and goods and services to which the insured person would be entitled if he or she had sustained a catastrophic impairment:

1. If the attendance of the insured person was not required for the examination under section 42, the day is the 15th 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. 18.