1. Reasonable fees charged by a health practitioner for preparing a disability certificate required under section 20, 35 or 37.
2. Fees charged in accordance with a Pre-approved Framework Guideline by a health practitioner for preparing a treatment confirmation form for the purposes of section 37.1.
3. Fees charged in accordance with a Pre-approved Framework Guideline by a member of a health profession for conducting an assessment or examination and preparing a report for the purposes of section 37.1.
4. Reasonable fees charged by a health practitioner for reviewing a treatment plan under section 38, and for approving it if appropriate.
5. Reasonable fees charged by a member of a health profession or a social worker for preparing an application under section 38.2 for approval of an assessment or examination.
6. Reasonable fees charged by a member of a health profession for preparing an assessment of attendant care needs under section 39.
7. Reasonable fees charged by a health practitioner for preparing an application under section 40 for a determination of whether the insured person has sustained a catastrophic impairment.
8. Fees charged for a designated assessment of the insured person.
9. Subject to subsection 24.1 (2), reasonable fees charged by a member of a health profession for consulting with a person who is conducting or has conducted an examination of the insured person under section 42, if the conditions set out in subsection 24.1 (1) are satisfied.
10. Reasonable fees and expenses in accordance with section 42.1 that are charged for an assessment or examination of the insured person and the preparation of a report of the assessment or examination.
11. Reasonable fees, other than fees referred to in any of paragraphs 1 to 10, that are charged by a member of a health profession or a social worker for conducting an assessment or examination and preparing a report if the assessment or examination is reasonably required in connection with a benefit that is claimed or in connection with the preparation of a treatment plan, disability certificate, assessment of attendant care needs or application for the determination of a catastrophic impairment, and,
i. the assessment or examination relates to ancillary goods or services described in section 37.2 and is contemplated by a treatment confirmation form submitted in accordance with section 37.1,
ii. the insured person applied for approval of the assessment or examination either in a treatment plan submitted under section 38 or by way of a separate application submitted under section 38.2, or
iii. The insurer approved the expense or the approval of the insurer is not required by reason of subsection (1.2). O. Reg. 546/05, s. 3 (1).
(1.1) Despite subsection (1), an insurer is not required to pay for an assessment or examination referred to in subparagraph 11 ii of subsection (1) if the expense for the assessment or examination is incurred,
(a) Before the insurer approves the expense;
(b) Before the insurer receives the report of an examination under section 42, if the insurer requires the insured person to be examined under that section; or
(c) Before the insurer receives the report of a designated assessment, in the case of an application for approval of an assessment or examination under section 38.2, if the insured person is required to undergo a designated assessment. O. Reg. 546/05, s. 3 (1).
(1.2) Despite subsection (1.1), the prior approval of an insurer is not required for the following:
1. An assessment or examination for the purposes of preparing a treatment plan under section 38 in circumstances in which an immediate risk of harm to the insured person or a person in the insured person’s care makes obtaining the prior approval of the insurer impractical.
2. Not more than three assessments or examinations for the purposes of preparing a treatment plan under section 38 if not more than one assessment or examination is done by the same person and the cost of each assessment or examination does not exceed $200.
3. An assessment or examination for the purposes of preparing a disability certificate under section 20, 35 or 37 if the cost of the assessment or examination does not exceed $200.
4. Revoked: O. Reg. 546/05, s. 3 (2).
5. An assessment or examination for the purposes of preparing an assessment of attendant care needs under section 39, but not an assessment or examination relating to an impairment that comes within a Pre-approved Framework Guideline unless the Guideline expressly states that the prior approval of the insurer is not required for the assessment or examination.
6. An assessment or examination for the purposes of determining if an insured person has a catastrophic impairment, if the insured person is hospitalized or is in a long-term care facility at the time of the assessment or examination.
7. An assessment or examination conducted after the insurer notifies the insured person that, before the assessment or examination is conducted, the insurer does not require the submission of a treatment plan under section 38 or an application for approval of an assessment or examination under section 38.2.
8. Revoked: O. Reg. 546/05, s. 3 (3).
O. Reg. 281/03, s. 7 (1); O. Reg. 546/05, s. 3 (2, 3).
(1.3)-(1.5) Revoked: O. Reg. 546/05, s. 3 (4).
(1.6) Subject to subsection (4), the insurer shall pay reasonable expenses incurred by or on behalf of an insured person for transportation expenses incurred in transporting the insured person to and from an assessment or examination referred to in subsection (1), including transportation expenses for an aide or an attendant. O. Reg. 281/03, s. 7 (1).
(2) The insurer is not liable under subsection (1) for 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. 7 (1).
(2.1) 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 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 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. 7 (1).
(3) Subject to subsection (4), the insurer is not liable under subsection (1.6) to pay 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. 24 (3); O. Reg. 303/98, s. 4 (2); O. Reg. 281/03, s. 7 (2).
(4) The insurer is not liable under subsection (1.6) to pay for expenses related to,
(a) the first 50 kilometers of transportation in the insured person’s automobile to and from an examination or assessment if the examination or assessment relates to an accident that occurred before April 15, 2004; or
(b) The first 50 kilometers of transportation to and from an examination or assessment if the examination or assessment relates to an accident that occurred after April 14, 2004, unless the insured person sustained a catastrophic impairment as a result of the accident. O. Reg. 458/03, s. 8.
(5) Vocational assessments referred to in clause 15 (5) (f) are not assessments for the purposes of this section. O. Reg. 281/03, s. 7 (4).
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