“Complicated” best describes the rules and procedures governing the private and public funding of services, devices and supplies for the rehabilitation of persons recovering from disabling injuries and illnesses. Nonetheless, anyone involved in the assessment, treatment or administrative aspects of rehabilitation will probably agree that knowledge of third-party benefits – their types, claiming procedures, coverage limits and exclusions – is not only essential from a patient relations standpoint, but it has tremendous influence on a practice’s financial health.

This review will subdivide benefits into two broad categories: those that pay for goods and services (such as vocational counselling, physiotherapy treatments, medications and assistive devices) and those that pay income according to predefined schedules or formulas.Two associated topics will not be reviewed in detail: payment precedence (which party, plan or program pays first when a person has multiple coverage for the same risks) and subrogation (an insurer’s right to recover payments already made to an insured from another insurer or third party by virtue of that insurer claiming the insured’s rights to payment). The rules governing payment precedence can be contentious, and their application can pull the rug out from under an insured’s otherwise well-laid plans for security. To protect readers from the consequences of precedence rules and subrogation, I will make two broad recommendations.

"Every policyholder should consider the purchase of optional coverage for personal injury benefits to be a mandatory component of their financial security program."

The first recommendation is to own one’s insurance as a named insured where possible. Someone who has a policy of health insurance or disability income insurance that names them as the owner of the policy, the policy’s insured and its beneficiary can be virtually certain that, in the event of a disabling injury or illness, the benefits they receive under such policies will not be offset by the benefits received under any other program or policy. For example, in practice, if your client or patient has such a policy and qualifies for an income benefit according to the policy’s definition of disability and other payment conditions, they will receive one hundred cents on each dollar of benefit plus the income benefits of any other policy or program for which they qualify. The second recommendation pertains to auto insurance. Because personal injury benefit cutbacks under Ontario auto insurance policies will start to be phased in for all but the catastrophically injured starting September 1, 2010, it is more important than ever that insureds purchase the maximum optional coverage prescribed by new Regulations 34/10 and 36/10. Current optional benefits have not been aggressively marketed by agents and brokers. If by the end of the summer your broker cannot price or explain the new optional benefits, look for a broker who can and advise your clients or patients to do the same. Every policyholder should consider the purchase of optional coverage for personal injury benefits to be a mandatory component of their financial security program.

Every resident of Ontario can be assured of at least some protection from the financial consequences of disability and the costs associated with rehabilitation. Regardless of the cause of one’s disabling injury or illness, the first line of funded acute care is the local hospital emergency department. For medical care it is OHIP, although OHIP coverage is not automatic, and has a number of eligibility criteria. (See www.health.gov.on.ca/en/public/programs/ohip/ohipfaq_dt.aspx for further details.) For in-home services it is the Community Care Access Centre. Another source of funding is group insurance, or employee benefits plans, from which payments for health, dental and disability benefits exceed $20 billion a year in Canada. Members of a group – most commonly employees of an employer who sponsors a plan – who satisfy the waiting period and other qualification requirements of those plans will have coverage under the plan’s benefits schedule. Benefits can be for health services not covered by OHIP, such as physiotherapy, psychological counselling, chiropractic treatments, private or semi-private hospital accommodation, medications not administered in a hospital, dental services and income replacement benefits. Note that under these plans benefits are typically, but not always, paid only if the illness or injury is non-occupational.

"Yet, many providers spend much uncompensated time on this activity. An aspiring social economist might consider it to be a worthy topic for their doctoral thesis"

If a person is covered under two group insurance plans at the same time, for instance under their employer’s plan as an employee and as a dependant under their spouse’s plan, it may be possible to claim reimbursement for expenses not covered by their primary plan from their secondary plan under “coordination of benefits” rules. These rules and their corresponding claiming procedures are detailed in the benefits booklets issued to the members covered under such plans.

Group insurance income replacement benefits such as STD or LTD can be taxable or non-taxable, depending on who pays the premiums, and are normally expressed as a percentage of employment income. High income earners in low-risk occupations can be eligible for benefits of $25,000 per month or more. Benefits can be reduced directly by other disability income sources such as CPP disability benefits, employment income and partial disability income benefits, and indirectly by what is referred to as the “all-source maximum.” They cannot be reduced by income benefits provided by a personal disability policy.

An employee working for a non-exempt occupation or employer who is injured while performing the duties of his or her job will be eligible for comprehensive health, dental, income replacement, vocational and rehabilitation benefits under a provincial workers compensation plan. Unlike in the United States where workers compensation is in essence a private system in 46 of the 50 states, workers compensation benefits in Canada are the responsibility of provincial governments. Workers compensation benefits are extensive. (Particulars for Ontario’s WCB benefits can be found at www.wsib.on.ca/wsib/wsibsite.nsf/public/WSIBBenefits.)Workers compensation programs are always first payers for occupational injuries or illnesses. In cases other than death or permanent disability, the administration of claims and payment mechanisms is highly procedural and integrated. Non-income benefits tend to be paid directly to the providers of goods and services. An increasing number of these claims and payment mechanisms are web-enabled. Certain workers compensation loss of earnings and future loss of earnings benefits can be offset by CPP disability income benefits.

"Every resident of Ontario can be assured of at least some protection from the financial consequences of disability and the costs associated with rehabilitation."

If a person is injured as the result of a motor vehicle collision, they will have coverage under the personal injury benefits schedules of their auto insurance policy. Ontario’s benefits are described in the Statutory Accident Benefits schedule. SABS is first payor for some benefits. It is last payor for the Income Replacement Benefit, in which case, it is last payor. A summary of the SABS can be found at www.fsco.gov.on.ca/english/insurance/auto/drs/default.asp#d.Those who have satisfied the contributory and service requirements of the Canada Pension Plan and meet its definition of disability may also qualify for the CPP disability benefit. The monthly benefit is determined according to a formula and increases with the number of dependent children. Again, group insurance disability benefits may be offset by such payments depending on whether the group plan specifies no offset (rare), an offset equivalent to the recipient’s own CPP benefits (common), or a full offset for all benefits received for themselves and their dependent children (less common now, given precedent-setting court cases).

So much protection, so many options. In fact, it takes a fertile imagination to think of a scenario under which someone who becomes ill or is injured will not have at least some of their income replaced or costs of service paid for by a third party under one or more benefits programs. The worst-case hypothetical scenario this writer could come up with – and an admittedly morbid one at that – is an unmarried, unemployed, newly resident adult citizen of another country, with negligible liquid assets and no personal health or disability insurance, who fails to heed a “do not swim – dangerous undertow” warning posted on a public beach and suffers an incapacitating brain injury due to oxygen deprivation. Chances of a successful tort action are slim, so the insurer of the municipality that owns the beach is excluded as a potential, eventual source of funds for the person’s acute, convalescent and rehabilitative care and related income needs. In Ontario, no hospital would turn this person away for their acute care needs, despite their lack of qualification for OHIP. This person would also likely qualify for some combination of (ODSP) Ontario Disability Support and/or social assistance for some of their income needs. If they are a refugee claimant, they may qualify for comprehensive health benefits provided under a federal program. They would not qualify for services from a Community Care Access Centre, so discharge to alternative care might be problematic, particularly if they have no relatives in Canada. The most prominent gap would likely be associated with ongoing primary care and rehabilitation.

Complexity appears to be the price we pay for a diverse benefits landscape and for the coordination required to ensure that benefits from all sources do not exceed indemnified losses or actual costs associated with assessments and treatments. A certain amount of complexity is also the by-product of controls employed to prevent fraud, promote adjudication equity and manage costs. Nonetheless, despite some attempts at streamlining and pre-approvals up to set limits, and some insurers’ exemplary practices in those areas, claiming for benefits can be a cumbersome, complex ordeal. To anyone – such as this writer – who has managed such programs and heard the term “abusers” applied to some perfectly legitimate claimants who happen to claim more than others, it is not surprising that a guilty-until-proven-innocent attitude creeps into some organizations’ claims processes.

"For practitioners, a 'whole person' view should include knowledge of patients’ and clients' funding sources."

“For practitioners, a ‘whole person’ view should include knowledge of patients’ and clients’ funding sources.”For practitioners, a “whole person” view should include knowledge of patients’ and clients’ funding sources. Some individuals may not understand their entitlements, and their insurers may not have had success explaining them. Yet, many providers spend much uncompensated time on this activity. An aspiring social economist might consider it to be a worthy topic for their doctoral thesis.