Accident Benefits and Your MVA Claim

Nov 29, 2022

Some Helpful Suggestions from Resolute Law Group*

What are accident benefits?

Alberta motor vehicle insurance policies must contain “Section B” Benefits which are also known as “accident benefits”. This part of your policy provides benefits to the policyholder, their family members, passengers and others, such as pedestrians and cyclists injured by the policyholder.

The Alberta standard automobile policy or SPF1 must contain Section B.

Are Section B benefits “no-fault”?

Sort of.  The purpose of the benefits is to provide a basic form of health insurance to people injured in motor vehicle accidents, regardless of who is at fault. This is different from the “no-fault compensation system in force in places like B.C. and Manitoba.  Accepting Section B benefits does not mean you don’t get any other compensation.

But I am not at fault for the accident, why does my policy respond?

If you were in a vehicle covered by an Alberta insurance policy, then your accident benefits policy will respond to cover YOUR expenses.  The other driver, if injured, will be covered by their accident benefits policy.

If you have passengers in your vehicle at the time of the collision your passengers will also be covered by YOUR accident benefits policy.

Were you a cyclist or a pedestrian?

In this event, you likely do not have any coverage of your own unless you have private health insurance.  However, the driver who struck you, if they are insured in Alberta, should have a Section B policy which will provide coverage to you for your basic healthcare expenses.

My Doctor says I am unable to work because of my Injuries what options do I have?

If you are unable to work, you may be eligible for Section B disability or ‘wage replacement benefits.

These disability benefits provide wage replacement for an individual who is “wholly disabled” following a motor vehicle collision.

The weekly benefit is $400 or 80% of the person’s average weekly earnings prior to the accident, whichever is lower.

To qualify for wage replacement, you must have been employed at the time of the accident or have worked a minimum amount of time in the year leading up to the accident. In addition, you have to work for more than 7 days before you can apply for the benefit.

What treatment does Section B cover?

Massage therapy, chiropractic care, acupuncture, and physiotherapy may all be covered. However, there are limits on how much is available to you.  Other treatments like psychology, vision care, medications and other items may also be covered.  Ask us.

How much is available to me?

The Section B policy should provide coverage of  $50,000 to each person for medically necessary treatment for a maximum period of two years, but there are limits on certain treatments.

• Massage has a maximum coverage of $350;
• Chiropractic treatment has a maximum coverage of $1,000; and
• Acupuncture has a maximum coverage of $350.[1]

The most individual claim’s under the Section B policy will not require the full limit of $50,000.

First, many individuals will heal fully before that limit is reached. Second, in our experience, most accident benefits insurers will restrict coverage and implement strategies to reduce the amount they have to pay.

My insurer is saying I am outside “the Protocol” and no longer authorized for treatment.

Accident benefit insurers have implemented a number of strategies to restrict coverage including a “Protocol” where they authorize 21 treatments or 3 months of treatment and advise individuals that they have reached the end of the “Protocol”.  The insurer often then states that no other treatment is authorized, leading the injured person to assume there simply is no other treatment available.

Nothing could be farther from the truth.

If you are:

• still injured or have a flare-up after this “Protocol”;
• your family doctor or another licensed practitioner agrees that further treatment is medically necessary; and
• you have not reached maximum coverage YOUR policy should “authorize” further treatment.

How come my accident benefits insurer requires me to use my health benefits first?

Accident benefits coverage is considered excess coverage to any other form of health insurance you have.  So, if you are married and your spouse has employment-related health benefits and you also have coverage under an employer-sponsored health plan, the accident benefits insurer is permitted to insist you use your private employer-sponsored health plans first.

But, we can help you to obtain the maximum benefit of the various plans available to you.  Call us.

I have a health spending account which allows me to use a certain amount of money on anything related to my health.  Do I have to use it for my MVA-related injury treatment?

In theory, your accident benefits insurer can insist that you use your health spending account before it has to make any payments to treatment providers on your behalf.

In reality, if you have already exhausted your health spending account by the time your bills for injury-related treatment come due, then the accident benefits insurer cannot insist on that.  For example, if you are engaging in physiotherapy treatment and know that you will have to start making payments at the end of January, there is no reason why you cannot attend dental treatment or buy yourself a new pair of glasses and put it under your health spending account before your physiotherapy appointments come due. Likewise, if you have a family that needs to use the health spending account for non-MVA-related injuries, then you may wish to consider using those amounts before you incur annual expenses for MVA-related treatment.  In this way, you can use your health spending account for what it was intended and require your accident benefits insurer to pay for your MVA-related injury treatment.

I am very confused about how I should use my different benefits.  What do I do?

We suggest you consider following the protocol below:

1. Go to see a medical doctor and ask them what specific forms of treatment you need. Get written notes stating what you need.
2. Find a treatment provider for the variety of treatments that you are prescribed and with whom you are comfortable. We suggest that you should get a treatment provider at a private clinic which is close to your home or work.  We do not recommend that you follow the advice of your insurance company, which may have its own reasons for sending you to a specific clinic.
3. Speak with the treatment provider (physiotherapist, chiropractor or massage therapist) about helping you to complete the forms to send to your accident benefits insurer.
4. Attend treatment even if your accident benefits insurer has not approved. Many Section B adjusters will wait two to four weeks before approving your treatment, while you remain injured and are suffering.
5. If for some reason your treatment is not approved by your Section B insurer, or approval is delayed, you should continue to obtain treatment and pay for it yourself. Make sure you save your receipts and send them to us so that we can submit them to Section B on your behalf. If your Section B provider will not pay, then we will claim that amount from the at-fault driver’s insurance company.
6. If you are unable to afford your own treatment and your Section B insurer has not approved it, speak with your treatment provider about entering what is called an “Assignment”. We can help you to do this, and effectively it is a method of financing your treatment so that the at-fault driver’s insurer pays your treatment provider at the end of your claim.
7. If your treatment provider is unwilling to enter an Assignment for you, but you wish to stay with that treatment provider, speak with us and we will find you a source of finance so that you can get the treatment you need even if you cannot afford it.

I do not like the physiotherapist or other treatment providers I have been attending. Can I switch clinics?

Yes, if you are dissatisfied with the treatment you are receiving at a clinic you can switch to a different clinic. However, it is highly unlikely your Section B provider will pay for an additional assessment at your new clinic.

If this is the case, we would recommend paying for the assessment yourself and providing us with a copy of the receipt to claim from the at-fault driver.

I cannot go to any treatment because my Section B adjuster says that I am cut off or my treatment plan has ended.  What do I do?

Remember that in Canada you are entitled to receive medical treatment regardless of what your insurance company wishes.  If your doctor believes you need a certain form of treatment or therapy, and you wish to take that treatment, then provided that it is available in Canada, you may pay for it and if it is a reasonable expense, it may be recovered from the at-fault driver’s insurance company.  This means that you may have to wait, or find a method of financing that treatment until your claim settles. However, while we are not doctors, we understand that it is better to receive treatment that doctors prescribe than to simply tough it out and suffer.

Call us and ask – we’ve been through this and can help you to find a treatment provider.

The bottom line is that your insurance adjuster is not a medical professional and does not have the right to control what treatment you receive. The accident benefits adjuster’s role is to pay for treatment as prescribed by Alberta statute and within the terms of your policy.  If they are unwilling to do so, Resolute Law Group can help you get your treatment paid for so you can get better.

[1] These are limits as of January 31, 2022. However, these limits are subject to change.

Disclaimer:

*The above information does not constitute legal advice.  This information is merely a collection of general information relating to the common terms of some motor vehicle policies.  Your particular circumstances along with your particular policy may significantly change or make incorrect the above information.  We provide this information only to our clients and only for their use in motor vehicle accident claims for which we represent them.  This is not intended to act as legal advice to any person at any time, and we caution our clients that any questions regarding the specific applicability of their own accident benefits policy to their situation must be obtained from Resolute Law Group lawyers directly.

“Resolute Law Group” is a registered trade name of Murray A. Harris Professional Corp.