November 15, 2017

Does Family Holiday Fall Within the Scope of Rehabilitation Expenses?

The case called F. V. v Wawanesa Mutual Insurance Company decided by the Licence Appeal Tribunal (LAT) on January 30, 2017 answers the question on whether or not family holiday expenses can be classified as payable rehabilitation benefit under section 16 of the Statutory Accident Benefits Schedule (SABS).

The Law

Section 16 of the SABS states, “Subject to section 18, rehabilitation benefits shall pay for all reasonable and necessary expenses incurred by or on behalf of the insured person in undertaking activities and measures described in subsection (3) that are reasonable and necessary for the purpose of reducing or eliminating the effects of any disability resulting from the impairment or to facilitate the person’s reintegration into his or her family, the rest of society and the labour market.”

Subsection 3 of section 16 of the SABS enumerates the following as rehabilitation activities and measures:

(a) Life skills training;

(b) Family counselling;

(c) Social rehabilitation counselling;

(d) Financial counselling;

(e) Employment counselling;

(f)  Vocational assessments;

(g) Vocational or academic training;

(h) Workplace modifications and workplace devices, including communications aids, to accommodate the needs of the insured person;

(i) Home modifications and home devices, including communications aids, to accommodate the needs of the insured person, or the purchase of a new home if it is more reasonable to purchase a new home to accommodate the needs of the insured person than to renovate his or her existing home;

(j) Vehicle modifications to accommodate the needs of the insured person, or the purchase of a new vehicle if it is more reasonable to purchase a new vehicle to accommodate the needs of the insured person than to modify an existing vehicle;

(k) Transportation for the insured person to and from counselling and training sessions, including transportation for an aide or attendant; and

(l) Other goods and services that the insurer agrees are essential for the rehabilitation of the insured person, and for which a benefit is not otherwise provided in this Regulation, except,

(i) Services provided by a case manager; and

(ii) Housekeeping and caregiver services.

The Case

In F. V. v Wawanesa Mutual Insurance Company, F. V. was injured in a motor vehicle accident. As a result of the accident, F. V. was considered as “catastrophically impaired”.

F.V. applied for rehabilitation benefits with his insurer Wawanesa Mutual Insurance Company. F. V. claimed that the expenses he incurred during a trip to Florida and Disney Land with his daughter’s family, including airfare tickets, accommodations, medical supplies and meals for the attendant fall under section 16 of the SABS as these expenses facilitated his reintegration back into his family.

The insurance company denied the rehabilitation benefits claim of F. V., saying that the expenses did not fall within the scope of rehabilitation benefits and they were not reasonable and necessary. As a result of the denial, F. V. submitted an application for dispute resolution with the LAT.

LAT Adjudicator Chloe Lester ruled in favor of the insurance company, concluding that the family holiday expenses of F. V. cannot be classified as a rehabilitation benefit.

Adjudicator Lester reasoned that the “other goods and services that the insured person requires” mentioned in subsection 3 (1) l of the SABS is not a “catch all” for other rehabilitation expenses. Adjudicator Lester added that the rehabilitation activities and measures “must be provided for by a professional and require a treatment goal or be a modification or device that accommodates the needs of the insured person.”

In the unfortunate event of a car accident, ensure you are prepared.

Download our FREE car accident app today!

Download our FREE accident benefit book

Click her to subscribe and get free insights delivered right to your inbox.