This consolidation is unofficial and is for reference only. For the official version of the regulations, consult the original documents on file with the Registry of Regulations, or refer to the Royal Gazette Part II. Regulations are amended frequently. Please check the list of Regulations by Act to see if there are any recent amendments to these regulations filed with the Registry that are not yet included in this consolidation. Although every effort has been made to ensure the accuracy of this electronic version, the Registry of Regulations assumes no responsibility for any discrepancies that may have resulted from reformatting. This electronic version is copyright © 2011, Province of Nova Scotia, all rights reserved. It is for your personal use and may not be copied for the purposes of resale in this or any other form.
Automobile Accident Diagnostic and Treatment Protocols Regulations
made under subsection 5(3) and Section 159 of the
Insurance Act
R.S.N.S. 1989, c. 231
O.I.C. 2013-21 (January 22, 2013, effective April 1, 2013), N.S. Reg. 20/2013
Citation
1 These regulations may be cited as the Automobile Accident Diagnostic and Treatment Protocols Regulations.
Definitions for the Act and regulations
2 (1) In these regulations,
“Act” means the Insurance Act;
“adjunct therapist” means any of the following:
(i) a massage therapist,
(ii) an acupuncturist,
(iii) an occupational therapist as defined in the Occupational Therapists Act;
“chiropractor” means a chiropractor as defined in the Chiropractic Act;
“evidence-informed practice” means the conscientious, explicit and judicious use of current best practice in making decisions about the care of a patient, that integrates individual clinical expertise with the best available external clinical evidence from systematic research while recognizing patient preference and individual patient considerations in the determination of treatment;
“health care practitioner” means any of the following who is licensed to practice their profession in the Province:
(i) a physician,
(ii) a chiropractor, or
(iii) a physiotherapist;
“history”, means, in respect of patient’s injury, all of the following:
(i) how the injury occurred,
(ii) the current symptoms the patient is experiencing,
(iii) anything the health care practitioner considers relevant from the patient’s past, including physical, physiological, emotional, cognitive and social history,
(iv) how the patient’s physical functions have been affected by the injury;
“IMC register” means the register of injury management consultants maintained under Section 24;
“injury management consultant” means a health care practitioner who is entered on the IMC register in accordance with Section 25;
“International Classification of Diseases” means the most recent version of the latest revision of the International Statistical Classification of Diseases and Related Health Problems, Canada, published by the Canadian Institute of Health Information based on the International Statistical Classification of Diseases and Related Health Problems published by the World Health Organization;
“patient” means an insured as defined in Section 104 of the Act;
“physiotherapist” means a physiotherapist as defined in the Physiotherapy Act;
“prescribed claim form” means a form approved by the Superintendent for the purpose of these regulations, and includes forms for assessments, treatment plans and concluding reports;
“protocols” means the diagnostic and treatment protocols established by these regulations for a sprain, strain or whiplash injury caused by an accident;
“spine” means the column of bone, known as the vertebral column, that surrounds and protects the spinal cord, and includes all of the following categorizations of the column according to the level of the body: cervical spine (neck), thoracic spine (upper and middle back) and lumbar or lumbosacral spine (lower back);
“sprain” means an injury to one or more tendons, to one or more ligaments, or to both tendons and ligaments;
“Section B benefits” means the benefits required under Section 140 of the Act as set out in Schedule 2 to the Automobile Insurance Contract Mandatory Conditions Regulations made under the Act;
“strain” means an injury to one or more muscles;
“treatment plan” means a treatment plan described in Section 18;
“whiplash-associated disorder injury” means a whiplash-associated disorder other than one that exhibits one or all of the following:
(i) neurological signs that are objective, demonstrable, definable and clinically relevant,
(ii) a fracture to the spine or dislocation of the spine;
“whiplash injury” means a whiplash-associated disorder injury;
(2) For the purpose of clause 159(1)(ka) of the Act and these regulations, “assessment” includes diagnosis.
Application of regulations
3 (1) These regulations apply to the examination, assessment and treatment or rehabilitation of strains, sprains and whiplash injuries suffered by an insured as a result of an accident in respect of which Section B benefits are payable.
(2) These regulations apply only if
(a) a patient wishes to be diagnosed and treated in accordance with the protocols; and
(b) a health care practitioner chooses to diagnose and treat the patient’s sprain, strain or whiplash injury in accordance with the protocols.
(3) Except as provided in subsection (4) or as necessary to process a claim under Sections 28 to 36 for treatment already provided, these regulations do not apply to an injury, and no treatment is authorized under these regulations, if 90 days have passed from the date of the accident in which the patient was injured.
(4) If a health care practitioner refers a patient to an injury management consultant under Section 23 within 90 days from the date of the accident, any examinations, further assessment, multi-disciplinary assessment or reports referred to in that Section may be completed under these regulations after the 90 days.
Scope of health care practitioner’s practice
4 Nothing in these regulations permits a health care practitioner to do anything that is outside the scope of their practice as determined by their governing body and legislation.
No independent medical examination
5 An insurer does not have the right to overrule a health care practitioner’s diagnosis under these regulations and cannot introduce an independent medical examination during treatment under these regulations.
Interpretative bulletins and information circulars
6 The Superintendent may issue interpretative bulletins and information circulars about any matter the Superintendent considers appropriate under these regulations, including any of the following:
(a) describing the roles and general expectations of persons affected by or who have an interest in the implementation, application, administration and operation of these regulations;
(b) respecting the implementation, application, administration and operation of these regulations.
Review of regulations
7 These regulations must be reviewed
(a) as part of the mandatory 7-year review of automobile insurance provided for in Section 159BA of the Act; or
(b) sooner or more often than as required by clause (a), at the discretion of the Superintendent, and the Superintendent must deliver the result of the review to the Minister.
Prescribed fees
8 (1) The Superintendent may prescribe the fees and disbursements or the maximum fees and disbursements to be paid for any service, activity or function authorized under these regulations, including any of the following:
(a) diagnostic imaging;
(b) laboratory testing;
(c) specialized testing;
(d) supplies;
(e) treatment plans;
(f) visits;
(g) therapies;
(h) assessments;
(i) reports and other prescribed claim forms.
(2) The fees and disbursements or maximum fees and disbursements prescribed under subsection (1) must be published in the Royal Gazette, Part I.
Diagnosis and Treatment Protocol for Strains and Sprains
Protocol established for strains and sprains
9 Sections 10 to 12 are established as the protocol for diagnosing and treating strains and sprains.
Developing diagnosis for strains and sprains
10 (1) Using evidence-informed practice and referring to the International Classification of Diseases, a health care practitioner must use the following process to diagnose a strain or sprain:
(a) take a history of the patient;
(b) examine the patient;
(c) make any ancillary investigation considered necessary;
(d) identify
(i) for strains, the muscle or muscle groups injured, and
(ii) for sprains, the tendons or ligaments, or both, that are involved and the specific anatomical site of the injury.
(2) A health care practitioner must use the diagnostic criteria set out in the following table to determine the degree of severity of a strain (as extracted from Orthopaedic Physical Assessment by David J. Magee, (5th), (2008), at page 29, and reproduced with permission from the publisher Elsevier Inc.):
1st Degree Strain
2nd Degree Strain
3rd Degree Strain
Definition of the degree of strain
few fibres of muscles torn
about half of muscle fibres torn
all muscle fibres torn (rupture)
Mechanism of injury
overstretch
overload
overstretch
overload
crushing
overstretch
overload
Onset
acute
acute
acute
Weakness
minor
moderate to major (reflex inhibition)
moderate to major
Disability
minor
moderate
major
Muscle spasm
minor
moderate to major
moderate
Swelling
minor
moderate to major
moderate to major
Loss of function
minor
moderate to major
major (reflex inhibition)
Pain on isometric contraction
minor
moderate to major
no to minor
Pain on stretch
yes
yes
not if it is the only tissued injured; however, often with 3rd degree injuries other structures will suffer 1st or 2nd degree injuries and be painful
Joint play
normal
normal
normal
Palpable defect
no
no
yes (if early)
Crepitus
no
no
no
Range of motion
decreased
decreased
may increase or decrease depending on swelling
(3) A health care practitioner must use diagnostic criteria set out in the following table to determine the degree of severity of a sprain (as extracted from Orthopaedic Physical Assessment by David J. Magee, (5th), (2008), at page 29, reproduced with permission from the publisher Elsevier Inc.):
1st Degree Sprain
2nd Degree Sprain
3rd Degree Sprain
Definition of the degree of sprain
few fibres of ligament torn
about half of ligament torn
all fibres of ligament torn
Mechanism of injury
overload
overstretch
overload
overstretch
overload
overstretch
Onset
acute
acute
acute
Weakness
minor
minor to moderate
minor to moderate
Disability
minor
moderate
moderate to major
Muscle spasm
minor
minor
minor
Swelling
minor
moderate
moderate to major
Pain on isometric contraction
no
no
no
Pain on stretch
yes
yes
not if it is the only tissued injured; however, often with 3rd degree injuries other structures will suffer 1st or 2nd degree injuries and be painful
Joint play
normal
normal
normal to excessive
Palpable defect
no
no
yes (if early)
Crepitus
no
no
no
Range of motion
decreased
decreased
may increase or decrease depending on swelling. dislocation or subluxation possible
Treatment protocol for strains and sprains
11 (1) During treatment under these regulations, a health care practitioner must treat a strain or a sprain by doing all of the following:
(a) educating the patient about the following matters:
(i) the desirability of an early return to 1 or more of the following, as they apply to the patient:
(A) their employment, occupation or profession,
(B) their training or education in a program or course,
(C) their usual daily activities,
(ii) an estimate of the probable length of time that symptoms will last, the estimated time for recovery and the length of the treatment process;
(b) managing inflammation and pain
(i) by the protected use of ice,
(ii) by elevating the injured area,
(iii) by compression, and
(iv) for a sprain, by using reasonable and necessary equipment to protect the sprained joint during the acute phase of recovery;
(c) teaching the patient about maintaining flexibility, balance, strength and the functions of the injured area;
(d) giving advice about self-care;
(e) preparing patient for a return to the following, as they apply to the patient:
(i) their employment, occupation or profession,
(ii) their training or education in a program or course,
(iii) their usual daily activities;
(f) discussing the disadvantage of depending on health care providers and passive modalities of care for extended periods of time;
(g) prescribing medication, if appropriate, including analgesics for the sole purpose of short-term treatment of the injury, such as non-opoid[opioid] analgesics, non-steroidal anti-inflammatory drugs or muscle relaxants, but treatment under these regulations does not include prescribing narcotics;
(h) subject to subsection (3), providing treatment that is appropriate and that the health care practitioner considers necessary to treat or rehabilitate the injury;
(i) referring the patient for any adjunct therapy that
(i) the health care practitioner considers necessary to treat or rehabilitate the injury, and
(ii) is linked to the continued clinical improvement of the patient.
(2) During treatment under these regulations for a 3rd degree strain or sprain, in addition to the treatment under subsection (1), definitive care of specific muscles, muscle groups, tendons or ligaments at specific anatomical sites, should be completed, including all of the following, as required:
(a) immobilization;
(b) strengthening exercises;
(c) surgery;
(d) if surgery is required, post-operative rehabilitation therapy.
(3) During treatment under these regulations, a health care practitioner must not treat a 1st or 2nd degree sprain or strain to a peripheral joint by a brief, fast thrust to move the joints beyond the normal range in the anatomical range of motion.
Diagnostic and treatment authorization for strains and sprains
12 (1) A health care practitioner is authorized to provide or approve any of the following in treating a 1st degree, 2nd degree or 3rd degree strain or sprain in accordance with Section 11:
(a) necessary diagnostic imaging, laboratory testing and specialized testing;
(b) necessary medication, as determined by the health care practitioner, except that narcotics are not authorized for reimbursement under these regulations;
(c) necessary supplies, in accordance with any guidelines that may be published by the Superintendent, to assist in the treatment or rehabilitation of the injury.
(2) The maximum number of treatment visits authorized under these regulations for treatment of strains and sprains is as set out in Section 19.
Diagnostic and Treatment Protocol for Whiplash Injuries
Protocol established for whiplash injuries
13 Sections 14 to 17 are established as the protocol for diagnosing and treating whiplash I and II injuries.
Developing the diagnosis for whiplash injuries
14 Using evidence-informed practice, a health care practitioner must use the following process to diagnose a whiplash injury:
(a) take a history of the patient;
(b) examine the patient;
(c) make any ancillary investigation considered necessary;
(d) identify the anatomical sites.
Diagnostic criteria for whiplash I and whiplash II injuries
15 (1) A health care practitioner must use all of the following criteria to diagnose a whiplash I injury:
(a) complaints of spinal pain, stiffness or tenderness;
(b) no demonstrable, definable and clinically relevant physical signs of injury;
(c) no objective, demonstrable, definable and clinically relevant neurological signs of injury;
(d) no fractures to or dislocation of the spine.
(2) A health care practitioner must use all of the following criteria to diagnose a whiplash II injury:
(a) complaints of spinal pain, stiffness or tenderness;
(b) demonstrable, definable and clinically relevant physical signs of injury including
(i) musculoskeletal signs of decreased range of motion of the spine, and
(ii) point tenderness of spinal structures affected by the injury;
(c) no objective, demonstrable, definable and clinically relevant neurological signs of injury;
(d) no fracture to or dislocation of the spine.
(3) An investigation to determine a whiplash II injury and to rule out a more severe injury may include any of the following:
(a) for cervical spine injuries, radiographic series in accordance with The Canadian C-Spine Rule for Radiography in Alter and Stable Trauma Patients, published in The Journal of the American Medical Association, October 17, 2001–Volume 286, No. 15;
(b) for thoracic, lumbar and lumbosacral spine injuries, radiographic series that are appropriate to the region of the spine that is injured, if the patient has 1 or more of the following characteristics:
(i) an indication of bone injury,
(ii) an indication of significant degenerative changes or instability,
(iii) an indication of polyarthritis,
(iv) an indication of osteoporosis,
(v) a history of cancer.
(5) The use of magnetic resonance imaging or computerized tomography is authorized only if 1 of the following conditions is met:
(a) a diagnosis cannot be determined from 3 plain view films;
(b) there are objective neurological or clinical findings.
Treatment protocol for whiplash I and whiplash II injuries
16 During treatment under these regulations, a health care practitioner must treat a whiplash I or whiplash II injury by doing all of the following:
(a) educating the patient about the following matters:
(i) the desirability of an early return to the following, as they apply to the patient:
(A) their employment, occupation or profession,
(B) their training or education in a program or course,
(C) their usual daily activities,
(ii) an estimate of the probable length of time that symptoms will last, the estimated time for recovery and the length of the treatment process,
(iii) that there is likely no serious currently detectable underlying cause of the pain,
(iv) the importance of postural and body mechanics control,
(v) that the use of a soft collar is not advisable,
(vi) the probable factors responsible for other symptoms the patient may be experiencing that are temporary in nature and that are not reflective of tissue damage, including
(A) disturbance of balance,
(B) disturbance or loss of hearing,
(C) limb pain or numbness,
(D) cognitive dysfunction, and
(E) jaw pain;
(b) giving advice about self-care;
(c) preparing the patient for return to the following, as they apply to the patient:
(i) their employment, occupation or profession,
(ii) their training or education in a program or course,
(iii) their usual daily activities;
(d) discussing the disadvantage of depending on health care providers and passive modalities of care for extended periods of time;
(e) prescribing medication, if appropriate, including analgesics for the sole purpose of short-term treatment of spinal injury, such as non-opoid[opioid] analgesics, non-steroidal anti-inflammatory drugs or muscle relaxants, but treatment under these regulations does not include prescribing narcotics;
(f) recommending
(i) pain management, as required,
(ii) exercise,
(iii) using heat and ice;
(h)[(g)] providing treatment that is appropriate and that the health care practitioner considers necessary to treat or rehabilitate the injury;
(h) referring the patient for any adjunct therapy that
(i) the health care practitioner considers necessary to treat or rehabilitate the injury, and
(ii) is linked to the continued clinical improvement of the patient.
Diagnostic and treatment authorization for whiplash I and whiplash II injuries
17 (1) A health care practitioner is authorized to provide or approve any of the following in treating a whiplash I or whiplash II injury in accordance with Section 16:
(a) necessary diagnostic imaging, laboratory testing and specialized testing;
(b) necessary medication to manage inflammation or pain, or both, except that narcotics are not authorized for reimbursement under these regulations;
(c) necessary supplies, as determined by the Superintendent, to assist in treating or rehabilitating the injury.
(2) The maximum number of treatment visits authorized under the protocol for diagnosing and treating whiplash I and II injuries is as set out in Section 19.
Treatment Plans, Limits and Referrals
Treatment plans
18 (1) A treatment plan describing the treatments that will be provided under the protocols must be prepared on a prescribed claim form.
(2) An insurer is not required to approve claims or provide payment for more than 1 treatment plan per patient per accident.
(3) A patient’s treatment plan must be completed by the health care practitioner who intends to provide the majority of treatment or who will be actively co-ordinating the care and treatment visits of the patient.
(4) A health care practitioner must provide copies of a patient’s treatment plan to all of the following:
(a) the patient’s insurer;
(b) all practitioners providing treatment for the patient;
(c) the patient.
(5) A health care practitioner who refers a patient to another health care practitioner for treatment in accordance with Section 22 must notify the other practitioner whether they have completed a treatment plan for the patient.
(6) Before treating a patient under the protocols, a health care practitioner must ask the patient if any other practitioner has been contacted about the patient’s injury and, if others have been contacted, must
(a) document any actions taken by the other practitioners; and
(b) contact the patient’s insurer to ensure no other treatment plan has been submitted or is anticipated.
Maximum number of visits authorized for treatment under protocols
19 (1) One visit to a health care practitioner for assessment of the injury or injuries is authorized for treatment of
(a) a single injury diagnosed and treated under the protocols; or
(b) 2 or more injuries from a single accident diagnosed and treated under the protocols.
(2) In addition to the assessment visit under subsection (1), the maximum number of visits authorized for treatment of an injury under these regulations is as set out in the following table:
Injury Diagnosed
Total Number of Visits Authorized
1st or 2nd degree strain or sprain
combined total of 10 visits to a physiotherapist, chiropractor or adjunct therapist
3rd degree strain or sprain
combined total of 21 visits to a physiotherapist, chiropractor or adjunct therapist
whiplash I injury
combined total of 10 visits to a physiotherapist, chiropractor or adjunct therapist
whiplash II injury
combined total of 21 visits to a physiotherapist, chiropractor or adjunct therapist
(3) Despite the number of visits authorized under subsection (2), for patients with 2 or more injuries from a single accident diagnosed and treated under the protocols, the following are the total number of visits authorized for treatment of the injuries under these regulations in addition to the assessment visit under subsection (1):
Multiple
Injuries Diagnosed
Total Number of Visits Authorized
A
2 or more of:
• 1st degree strain
• 2nd degree strain
• 1st degree sprain
• 2nd degree sprain
• whiplash I injury
combined total of 10 visits to a physiotherapist, chiropractor or adjunct therapist
B
1 or more of the injuries in row A plus 1 or more of:
• 3rd degree strain
• 3rd degree sprain
• whiplash II injury
combined total of 21 visits to a physiotherapist, chiropractor or adjunct therapist
C
2 or more of:
• 3rd degree sprain
• 3rd degree strain
• whiplash II injury
combined total of 21 visits to a physiotherapist, chiropractor or adjunct therapist
Assessment for injury to which regulations do not apply
20 Despite Section 3, if after an assessment a physiotherapist or a chiropractor diagnoses an injury as one to which these regulations do not apply, the assessment may be claimed under these regulations.
Referrals to other health care practitioners
21 A health care practitioner may refer a patient to another health care practitioner or to an adjunct therapist in accordance with the protocols, and any visits to the referred health care practitioner or adjunct therapist are authorized in accordance with the limitations set out in Section 19.
Applying to insurer for approval of additional Section B services or supplies
22 Nothing in these regulations prevents or limits a patient or a health care practitioner from applying to an insurer for approval of additional treatments by a health care practitioner or adjunct therapist outside the limits specified by these regulations in accordance with the Act and the Section B benefits.
Referral to injury management consultant
23 (1) A health care practitioner may refer a patient for 1 visit to an injury management consultant of the health care practitioner’s choice in any of the following circumstances:
(a) the health care practitioner is uncertain about an injury to which the protocols apply or the diagnosis or treatment of the injury;
(b) the health care practitioner requires another opinion or report because they believe that the injury is not
(i) resolving appropriately, or
(ii) resolving within the time expected;
(c) the health care practitioner believes the patient exhibits limitation of a physical or cognitive function that results in the patient’s inability to perform any of the following:
(i) the essential tasks of their regular employment, occupation or profession despite reasonable efforts to accommodate their injury and the patient’s reasonable efforts to use the accommodation to allow them to continue their employment, occupation or profession,
(ii) the essential tasks of their training or education in a program or course that they were enrolled in, or had been accepted for enrolment in at the time of the accident, despite reasonable efforts to accommodate their injury and the patient’s reasonable efforts to use the accommodation to allow them to continue their training or education,
(iii) their usual daily activities;
(d) the health care practitioner has a difference of opinion about the diagnosis or treatment of the injury with another health care practitioner that cannot be resolved.
(2) On a visit referred under subsection (1), an injury management consultant may complete an assessment and prepare a report that must include 1 of the following:
(a) advice about the diagnosis or treatment of the patient;
(b) a recommendation for a multi-disciplinary assessment of the injury, or an aspect of the injury, and the health care practitioners who should be included in that assessment.
(3) The visit and the costs and expenses related to an assessment and report by an injury management consultant under subsection (2) may be claimed under these regulations, and the visit does not count toward the total limits on visits in Section 19.
(4) Other than the visit, assessment and report described in this Section, no further visit to or assessment or report by an injury management consultant in respect of the same injury is authorized under these regulations.
Injury Management Consultants Register
Register maintained by Superintendent
24 (1) The Superintendent must maintain and administer a register of injury management consultants.
(2) The Superintendent must ensure that the IMC register is published in a form and manner that makes the register accessible to the public.
Eligibility requirements for injury management consultants
25 (1) A health care practitioner is an injury management consultant under these regulations if the Superintendent is notified by the following body that the person meets the requirements set out in subsection (2), and the Superintended[Superintendent] enters the person’s name in the IMC register:
(a) for a physician, by the College of Physicians and Surgeons of Nova Scotia;
(b) for a chiropractor, by the Nova Scotia College of Chiropractors;
(c) for a physiotherapist, by the Nova Scotia College of Physiotherapists.
(2) A person is eligible to be an injury management consultant if the person meets any qualifications established by the Superintendent and approved by the relevant colleges, including all of the following qualifications:
(a) they are an active practising member of their profession;
(b) they are knowledgeable about the biopsychosocial model;
(c) they are knowledgeable about assessing acute and chronic pain;
(d) they are experienced in rehabilitation and disability management;
(e) they use evidence-informed practices in their practice.
Ceasing to be an injury management consultant
26 A person ceases to be an injury management consultant when all of the following conditions are met:
(a) the college for the person’s profession notifies the Superintendent that the person’s name is to be removed from the IMC register;
(b) the Superintendent removes the person’s name from the IMC register.
Claims and Payment of Claims
Definitions for Sections 27 to 36
27 In this Section and Sections 28 to 36,
“applicant” means a patient or health care practitioner who sends a completed prescribed claim form to the insurer in accordance with Section 29;
“business day” means any day other than a Saturday, Sunday or a holiday as defined in the Interpretation Act.
Priority of Sections 27 to 36
28 Sections 27 to 36 prevail in respect of any inconsistency or conflict between these provisions and the required Section B benefits.
Sending claim to insurer
29 (1) A patient or health care practitioner may not make a claim under these regulations until the patient has completed the applicable prescribed claim form for their injury.
(2) The completed prescribed claim form under subsection (1) must be sent to the insurer no later than
(a) 10 business days after the date of the accident; or
(b) if the deadline in clause (a) is not reasonable, as soon as practicable.
Decision by insurer
30 (1) No later than 5 business days after receiving a completed prescribed claim form, an insurer must send the applicant a decision notice that
(a) approves the claim; or
(b) refuses the claim, including the reasons for refusing the claim.
(2) A claim may be refused by an insurer for the following reasons only:
(a) the person who was injured does not meet the definition of “patient”;
(b) the insurer is not liable to pay as a result of an exclusion set out in Subsection 3 - Special Provisions, Definitions and Exclusions of this Section of the Section B benefits;
(c) there is no existing contract that applies to the person who was injured;
(d) the injury was not caused by an accident arising out the use or operation of an automobile.
(3) If an insurer indicates to a health care practitioner that no other treatment plans have been submitted or are anticipated in respect of a patient, the insurer must not refuse any prescribed claim forms submitted by the health care practitioner in respect of the treatment plan for that patient.
If insurer does not respond to applicant
31 If an insurer does not send a decision notice back to the applicant in accordance with Section 30, then the insurer is deemed to have approved the claim.
Denial of liability after approval or deemed approval
32 (1) An insurer who approves a claim, or is deemed to have approved a claim, may later refuse the claim by sending a notice in writing to all of the following, including the reasons why the claim is denied:
(a) the patient;
(b) each person that the patient is authorized to visit or is authorized to provide services or supplies to the patient.
(2) An insurer may refuse a claim under subsection (1) for the reasons set out in subsection 30(2) only.
(3) A notice under this Section takes effect on the date it is received by the person to whom it is sent and, on and after the date the patient receives the notice, the insurer is not liable to pay any future claims under these regulations relating to the patient’s injuries.
Making and paying claims
33 (1) Any treatment that is authorized under these regulations may be the subject of a claim under subsection (2).
(2) No later than 30 days after receiving it, an insurer must pay any claim for treatment that is authorized under these regulations and that meets all of the following conditions:
(a) it includes all related invoices and, if submitted by a patient, receipts for the supplies and services claimed together with satisfactory evidence that the treatment is authorized by these regulations;
(b) if submitted by a health care practitioner, injury management consultant or adjunct therapist, it is verified by the patient treated.
Sending notices
34 Any notice required or permitted to be sent under Sections 28 to 36 may be sent by any of the following methods:
(a) delivered personally;
(b) mailed;
(c) faxed;
(d) transmitted by e-mail, if both parties agree to this method of sending and receiving notices.
Multiple claims
35 For greater certainty, a person who has a claim under these regulations and a claim for other benefits as set out in Subsection 3 - Special Provisions, Definitions and Exclusions of this Section of the Section B benefits, must comply with these regulations and the Section B benefits, according to the claim or claims made.
Concluding report and final invoice
36 (1) The health care practitioner who completed the majority of treatments for a patient must prepare a concluding report on a prescribed claim form and send it to the insurer after treatment under these regulations is completed.
(2) A health care practitioner must send the patient a copy of the final invoice they sent to the insurer, together with a standard letter that includes the following statements:
“We have billed your insurer the amounts shown on the attached invoice for the goods and services listed. Please check the invoice and report any errors to us and to your insurer.”