Have you been told by a healthcare provider that you are suffering from a strain, sprain or whiplash associated disorder (WAD)? If so there are peculiarities to obtaining treatment through your section B insurer that you should be aware of. This situation is covered by the Diagnostic and Treatment Protocols Regulation a part of the Insurance Act.
What is The Diagnostic and Treatment Protocol?
Where a patient has been diagnosed with a sprain, strain or certain types of WAD Injury and seeks treatment for such a law called the Diagnostic and Treatment Protocols Regulation applies (at least until either 90 days from the date of the accident have elapsed or the patient has met the number of treatments that the regulation entitles them to).
Where a 1st or 2nd degree strain/sprain or a WAD I injury is diagnosed a healthcare provider may authorize a combined total of up to 10 physical therapy, chiropractic, and adjunct therapy visits (which includes dentists, occupational therapists, and psychologists). Where there is a 3rd-degree strain/sprain or WAD II injury this number increases to 21 combined total physical therapy, chiropractic, and adjunct therapy treatments. The interesting factor here though is that these number of treatments may be authorized by your treatment provider without the approval of the insurance company, that is they can be billed without having to sign off on the treatments. Furthermore where one or more of a 1st/2nd-degree strain, 1st/2nd-degree sprain, or WAD I injury is diagnosed the number permitted for direct billing is 10 treatments. Where any of these in addition to a 3rd-degree strain/sprain or a WAD II injury (or if there are more than one of 3rd-degree strains/sprains/WAD II injuries) are diagnosed the number permitted to be directly billed in this matter is limited to 21 treatments. Regardless, however, even where your injury falls under the regulation notice of the claim still has to be submitted within 10 days of the accident using an AB-1 form for Proof of Loss and Notice of Claim. Your attending practitioner should also generally complete an AB-2 Treatment Plan Form during this time frame. Additionally, an AB-4 Concluding Report should also generally be submitted within 15 to 90 days of the collision. The insurer may further ask for AB-3 Progress Report Forms which only need to be completed upon request.
What Do They Mean “Outside The Treatment Protocol”?
Any treatments in excess of these numbers would fall outside the regulation. Meaning they would have to be approved and the insurer may require that you pay out of pocket then submit receipts for reimbursement.
Another factor here is that if these treatments are completed within 90 days, they will be directly billed to the section B insurer for your automobile, treatments completed past this time are likewise considered outside the regulation and are subject to being paid out of pocket and submitted for reimbursement & approval unless the insurer allows an exemption.
What About WAD III and WAD IV
Injuries such as WAD III and IV, fall outside of the Diagnostic and Treatment Protocols Regulation and as such required treatments would have to be paid out of pocket and reimbursed subject to policy limits. The standard auto policy in Alberta (the SPF-1) indicates that such treatments will be reimbursed if incurred within 2 years subject to a $50, 000.00 limit. Though chiropractic services are limited to $1000, massage treatment is limited to $350, and acupuncture is limited to $350. Physiotherapy does not have a limit and must be reimbursed so long as within this time frame and considered medically necessary.
Where treatments are outside the Diagnostic and Treatment Protocols Regulation, standard section B rules apply, meaning that any private benefits would be used to pay for treatment prior to the section B insurer kicking in.
Navigating Whiplash Injury Law with James H. Brown and Associates
Since 1993, James H. Brown and Associates has become a trusted name in Alberta accident injury law. Our experienced team of injury lawyers understands firsthand what it’s like to be seriously injured, and has over 200 years of combined experience attaining justice and fair compensation for our clients in Edmonton and across Alberta.
Every whiplash-related injury is unique, and no two cases are the same; that’s why we offer a complete range of services and support for our clients, including:
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