(2) Within 10 business days after receiving the assessment of attendant care needs, the insurer shall give the insured person a notice that,
(a) advises the insured person which, if any, expenses described in the assessment of attendant care needs the insurer agrees to pay; and
(b) advises the insured person that the insurer requires the insured person to be examined under section 42, if the insurer has not agreed to pay all expenses described in the assessment of attendant care needs. O. Reg. 546/05, s. 17.
(3) An insurer may, but is not required to, pay an expense incurred before an assessment of attendant needs that complies with subsection (1) is submitted to the insurer. O. Reg. 546/05, s. 17.
(4) The insurer shall begin payment of attendant care benefits within 10 business days after receiving the assessment of attendant care needs and, pending receipt by the insurer of the report of any examination under section 42 required by the insurer, shall calculate the amount of the benefits based on the assessment of attendant care needs. O. Reg. 546/05, s. 17.
(5) If an insurer wants to determine if an insured person is still entitled to attendant care benefits, wants to determine if the benefits are being paid in the appropriate amount or wants to determine both, the insurer shall give the person a notice requesting that a new assessment of attendant care needs for the insured person that complies with subsection (1) be submitted to the insurer within 10 business days after the insured person receives the notice. O. Reg. 546/05, s. 17.
(6) Subject to subsection (10), a notice under subsection (5) may also advise the insured person that the insurer requires the insured person to be examined under section 42. O. Reg. 546/05, s. 17.
(7) Subject to subsection (10), new assessments of attendant care needs may be submitted to an insurer at any time there are changes that would affect the amount of the benefits. O. Reg. 546/05, s. 17.
(8) If a new assessment of attendant care needs indicates that it is appropriate to increase the amount of the attendant care benefits and the insurer has not already advised the insured person that the insurer requires the insured person to be examined under section 42, the insurer may give a notice to the insured person advising that the insurer requires the insured person to be examined under section 42. O. Reg. 546/05, s. 17.
(9) If a new assessment of attendant care needs is required under subsection (5) or the insurer requires an examination under section 42, the insurer shall, subject to section 18, continue to pay the insured person attendant care benefits at the same rate until the insurer receives the assessment of attendant care needs or the report of the examination, as applicable. O. Reg. 546/05, s. 17.
(10) If more than 104 weeks have elapsed since the accident, the insurer shall not require the insured person to be examined under section 42 to determine the insured person’s entitlement to attendant care benefits and the insured person shall not submit nor be required to submit an assessment of attendant care needs to the insurer unless,
(a) the insured person is or may be entitled under section 18 to receive attendant care benefits more than 104 weeks after the accident; and
(b) at least 52 weeks have elapsed since the last examination under section 42. O. Reg. 546/05, s. 17.
(11) 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 the benefit to the insured person and to the member of the health profession who prepared the assessment of attendant care needs. O. Reg. 546/05, s. 17.
(12) The insurer’s determination shall specify the benefits and expenses the insurer agrees to pay, the benefits and expenses the insurer refuses to pay and the reasons for the insurer’s decision. O. Reg. 546/05, s. 17.
(13) If an insured person fails or refuses to comply with subsection 42 (10), the insurer may,
(a) make a determination that the insured person is not entitled to attendant care benefits; and
(b) refuse to pay attendant care benefits relating to the period after the 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). O. Reg. 546/05, s. 17.
(14) 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 new determination, resume payment of attendant care benefits; and
(c) pay all amounts, if any, that were withheld during the period of non-compliance, if 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. 17.
(15) If an insurer determines that an insured person is not entitled, by reason of section 18, to attendant care benefits for expenses incurred more than 104 weeks after the accident, the insurer shall give the insured person a notice of its determination, with reasons, not less than 10 business days before the last payment of attendant care benefits. O. Reg. 546/05, s. 17.
(16) An assessment of attendant care needs under this section in respect of accidents occurring on or after March 31, 2008 shall be in the form of and contain the information required in the “Assessment of Attendant Care Needs” dated March 1, 2008 and available on the website for the Financial Services Commission of Ontario. O. Reg. 63/08, s. 1.
(16.1) Revoked: O. Reg. 63/08, s. 1.
(17) An assessment of attendant care needs under this section in respect of accidents occurring on or after February 1, 2007 but before March 31, 2008 shall be in the form of and contain the information required in the “Assessment of Attendant Care Needs” dated December 31, 2006 and available on the website for the Financial Services Commission of Ontario. O. Reg. 63/08, s. 1.
(18) An assessment of attendant care needs under this section in respect of accidents occurring on or after March 1, 2006 but before February 1, 2007 shall be in the form of and contain the information required in the “Assessment of Attendant Care Needs” dated December 31, 2005, as it read on March 1, 2006 and available on the website for the Financial Services Commission of Ontario. O. Reg. 63/08, s. 1.
(19) An assessment of attendant care needs under this section in respect of accidents occurring before March 1, 2006 shall be in Form 1, as it read on February 28, 2006 and available on the website for the Financial Services Commission of Ontario. O. Reg. 63/08, s. 1.
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