In this age of fingerprint readers and PINs, I find it relieving
to see that the old-fashioned signature can still hold sway.
Indeed, the existence of a signature in accident benefits claims
can make or break a file. In the recent case of Chaparina and
State Farm1, Arbitrator Sapin, the procedural maven
of the Financial Services Commission2, concluded that
State Farm did not have to pay disputed medical benefits because
treatment plans were not signed by both the claimant and the health
practitioner who allegedly completed it. This ruling proves that
accident benefits insurers must pay close attention to the details
of treatment plans.
At the hearing, State Farm argued that the disputed treatment
plans were invalid because they had not been signed by the claimant
and her health practitioner, as required by subsection 38(3) of the
Statutory Accident Benefits Schedule (O. Reg. 34/10):
(3) A treatment and assessment plan must,
(a) be signed by the insured person unless the insurer waives
(b) be completed and signed by a regulated health
The failure of the claimant to sign the treatment plan meant
subsection 38(2) relieved State Farm of the responsibility to pay
(2) An insurer is not liable to pay an expense in respect of a
medical or rehabilitation benefit or an assessment or examination
that was incurred before the insured person submits a treatment and
assessment plan that satisfies the requirements of subsection
Arbitrator Sapin concluded that the language of section 38 is
"clear and straightforward". She held that this language
confirms that an insurer is under no obligation to pay for the
services described in a treatment plan that was not signed by the
claimant and her health practitioner.
In light of Chaparina, I recommend accident benefits insurers
never waive the requirement to have the claimant sign the treatment
plan (which insurers are allowed to do pursuant to paragraph
38(3)(a)), absent exceptional circumstances that are
well-documented by the adjuster handling the file. The requirement
that both the claimant and the health practitioner sign the
treatment plan helps prevent fraud and ensures that both the
claimant and health practitioner agree that the requested treatment
is needed (indeed, Ms. Chaparina admitted at the arbitration that
she had not known about the treatment plans and did not receive the
Arbitrator Sapin mentioned in passing that it would have been
better if State Farm raised the issue of the unsigned treatment
plan before the hearing. Her words suggest that State Farm may have
an obligation to inform the claimant of the importance of signing
treatment plans. This obligation is consistent with the general
responsibility of an accident benefits insurer to ensure that
claimants understand how to claim benefits.
Those of us who work in the field of accident benefits know that
treatment plans that are submitted via the Health Claims for Auto
Insurance service are not signed. That does not relieve the
claimant and the health practitioner of their obligation to sign
the document. It is a good idea for the accident benefits insurer
to request the clinical notes and records of the facility that
submitted the disputed treatment plans. Those clinical notes should
contain a copy signed by both the claimant and the health
practitioner. A lack of signed copies should raise eyebrows and may
prove decisive at a later arbitration.
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