If the attendant care benefit is denied at first instance, it will be referred to an IE. This is an opportunity for a doctor or health care professional selected by, and paid by the insurer to determine if the proposed attendant care benefit is reasonable and necessary. It can take time to get the IE set up. It can take time for the IE report to get generated. While all of this waiting is happening, the accident victim is not getting any attendant care benefits, unless they are paying for these attendant care benefits out of their own pocket, or from a collateral benefit plan.
Should the IE report come back and deem the attendant care benefits to be reasonable and necessary, then the attendant care benefits will be approved and paid.
By the time the LAT hearing takes place, a lot of time will have passed, without any attendant care benefits getting paid out to the injured accident victim. First, a person like an occupational therapist will need to complete an Assessment of Attendant Care Needs Form 1. The Form 1 sets out the quantum of time required for your attendant care, and over what areas the attendant care is required. Without a Form 1 getting completed, you will not receive any attendant care benefits, unless you have a very kind and generous insurance adjuster.
The reality is that this benefit favours wealthy people who can afford to pay their family members, over non wealthy people who may not have the disposable income. These laws also favour the gainfully employed over the unemployed, retired or disabled.
What we see more of are professional attendant care services providers getting involved in the provision of attendant care. That way, there is no dispute between the accident victim and the insurance company whether or not the attendant care expense is incurred or not. This eliminates a potential barrier to recovery and also ensure that the attendant care services are being provided by a qualified professional. But just because a professional business is involved, does not always mean that benefits will flow.
Yes, the insurer is entitled to a deduction for the portion of the attendant care expenses that are reasonably available to you under any insurance plan or any other plan or law. If the claimant hires a professional attendant the full monthly amount provided for in the Guidelines will be payable. If the attendant is not a professional, such as a friend or family member, the attendant care payable cannot be more than the amount of money the attendant lost during the time they were providing services for the claimant section 19 3 , SABS.
Attendant Care benefits are to be paid monthly. Payments must be made within 30 days after receiving an invoice for them section 38 15 , SABS. Under 18 years old at the time of the accident, non-catastrophic: until 18th birthday or until death if optional benefits were purchased.
The procedure for claiming for attendant care benefits as set out in section 42 of the SABS which you can find here. To apply for attendant care benefits, you must retain a registered nurse or occupational therapist to complete a Form 1. The assessor must provide a copy of the Form 1 to the you, your health practitioner, your lawyer, and the insurance company. It is important that you submit the Form 1 as soon as possible. Section 42 5 of the SABS provides that the insurer may pay attendant care prior to its submission but must pay it after.
The Form 1 comprises 5 Parts. Parts set out the various attendant care services, Part 4 sets out the calculation of the monthly amount, and Part 5 is the signature of the assessor:. There is some ambiguity to this section as to whether a Form 1 can be retroactively submitted. Guarantee Co. Within 10 business days after receiving the assessment of attendant care needs, the insurer shall give you a notice specifying:.
There is the odd assessor that we see who is impartial. To reassess, your insurance company must send you a notice, requiring you to submit a new Form 1 within 15 days. Your insurance company may also at this time request a new section 44 assessment. Any time there are changes that would affect the amount of attendant care benefit received, you may submit a new Form 1.
If the new Form 1 indicates that a new amount is in order, your insurance company has the right to its own section 44 assessment. Pending the receipt of the new Form 1, payments for the existing Form 1 should continue at the same rate. Yes — your insurance company must provide you with a benefit statement when the amount of the attendant care is first paid, or when the amount of the benefit is adjusted.
If you have suffered a serious injury and require attendant care benefits, our Hamilton personal injury lawyers can help. We represent vicitms involved in motorcycle accidents , bicycle accidents , trucking accidents, car accidents , and pedestrian accidents.
Call our Hamilton Lawyers at or send us a confidential message through our online contact form to set up a free, no-obligation consultation. And remember, we will never ask for money upfront. I call Matt my knight in shining armour.
After I was struck by a car while cycling and permanently crippled, he fielded all communications with my especially difficult and downright nasty insurance adjuster. Every step of my care was a battle and I did not have the strength to fight alone. Attendant Care Benefits. Home Attendant Care Benefits. What are Attendant Care Benefits? What are the criteria to qualify for an Attendant Care Benefit?
Incurred by or on behalf of the insured. As a result of the accident. For services provided by either: an aide or attendant; a long-term care facility; chronic care assistance What about transportation expense? Transportation expenses are payable under this section if they are section 19 1 b , SABS : Authorized transportation expenses; Not related to a medical or rehabilitation expense; Not related to a transportation expense to a medical examination section 25 4 , SABS.
In order to maximize your chance of success of obtaining attendant care benefits, you should: Ensure that the impairment requiring the assistance is documented through reliable medical records and reports. Establish that the amount of time requested is justified. Explain to your clients that credibility is key: they should always tell the truth and resist the urge to exaggerate.
Provide evidence that the services have been provided: be as detailed as possible. Take care to differentiate the attendant care services from non-attendant care-related services. What does it mean to have an incurred expense?
The Accident Benefit schedule provides a general definition of incurred in section 3 7 e. The claimant has either: paid the expense, promised to pay the expense, or is otherwise legally obligated to pay the expense. The person who provided the goods or service: did so in the course of the employment, occupation or profession in which he or she would ordinarily have been engaged, but for the accident, or sustained an economic loss as a result of providing the goods or services to the insured person The Court of Appeal, in a case called Henry v.
Gore held that attendant care services are goods and services according to this definition. What about a student dropping out of school to provide attendant care benefits?
Possibilities include: Loss of tuition or other educational costs that may have been thrown away. Delayed entry into the work force. Restricted career potential. Other possible consequent forms of economic loss at paragraph What about stay at home parents that are not professionals? Can attendant care services be provided electronically? Text message. Video conferencing such as Skype, Facetime. What if there are benefit exclusions? What are the maximum amounts claimable for Attendant Care Benefits?
The maximum amount available to a claimant for attendant care benefits depends on whether the claimant: Had an accident before or after June 1, Falls under the Minor Injury Guidelines. Is designated as catastrophic or non catastrophic. Has purchased optional benefits. Can Attendant Care Benefits be indexed to inflation? Does my insurance company get to deduct or set-off other benefits from my Attendant Care Benefit?
What is the difference between the amounts payable with respect to professional vs.
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