What Constitutes One Assessment under Statutory Accident Benefits Schedule

The Statutory Accident Benefits Schedule (SABS) – a regulation under the Insurance Act – sets the maximum amount that an insurance company is required to pay for one assessment of the extent of an accident victim’s injury at $2,000.

Section 25, paragraph 5a of SABS, specifically states that “an insurer shall not pay, more than a total of $2,000 in respect of fees and expenses for conducting any one assessment or examination and for preparing reports in connection with it, whether it is conducted at the instance of the insured person or the insurer.”

The case called Nicole Breadner v. Co-operators General Insurance Company decided by Arbitrator Caroline King of the Financial Services Commission of Ontario (FSCO) on January 11, 2017 defines the scope of “one assessment” under section 25, paragraph 5a of SABS.

Breadner, in this case, was injured by a motor vehicle when she was crossing a road. Breadner submitted a Treatment and Assessment Plan, also known as OCF-18 form, to her insurer Co-operators General Insurance Company asking the insurance company to pay for her neuropsychological assessment expenses amounting to $5,028.50.

The breakdown of Breadner’s neuropsychological assessment expenses is as follows:

  • Neuropsychological interview: $2,000
  • Neuropsychological testing: $2,000
  • Neuropsychological screen related to the OCF-18: $250
  • OCF-18: $200
  • Subtotal: $4,450
  • Taxes: $578.50
  • Grand total: $5,028.50

Co-operators only paid Breadner $2,000 for the cost of one assessment, plus $200 related to the completion of the OCF-18 form and related taxes.

Breadner asked the assistance of FSCO to require Co-operators to pay a total of $2,828.50 for her other neuropsychological assessment and interest for the overdue payment of benefits, arguing that two neuropsychological assessments were conducted on her. The insurance company, on the other hand, argued that it has paid its obligation to Breadner as there was only one assessment.

Arbitrator King ruled in favor of the insurance company, saying that there was only one assessment in this case. “The law (Statutory Accident Benefits Schedule) clearly anticipates that an assessment may include more than one report,” Arbitrator King said.

The arbitrator added that despite the fact that there were two reports on Breadner, one report called “Independent Neuropsychological Examination Interview & Analysis” and another report called “Independent Neuropsychological Examination Testing,” these two documents or reports were considered as one as they had the following similar features:

  • Same purpose;
  • Same author;
  • Issued on the same date;
  • Same dates of examination;
  • Same “Tests Administered”; and
  • Results and information in the second document were incorporated by reference into the first document.