As amended, June 1998
TABLE OF CONTENTS
- Disability Assessments
- Medical and Rehabilitation Assessments
- Attendant Care Assessments
- Catastrophic Impairment Assessments
- When is a Claimant Referred for a DAC Assessment?
- Terms CONFIDENTIALITY
- CONFLICT OF INTEREST
- DAC Responsibilities
- Future Assessments and Treatment
- Designated Assessors
- Continuation of Benefits
- The Disability Assessment Process
- The Medical and Rehabilitation Assessment Process
- The Attendant Care Assessment Process
- The Catastrophic Impairment Assessment Process
- Initiating a Referral
- Nearest DAC
- Responsibilities of the Insurer
- Referral Information
- Time Frame
- DAC Intake Responsibilities
- Assessment Responsibilities
- Time Frame
- Content of the DAC Report
- Style and Language
- Recommending Providers
- Other Issues
- Time Frame
- Monitoring and Evaluation
- Further Information
Disability Certificate (OCF-3/59)
Designated Assessment Referral and Summary Report (OCF-11/59)
Permission to Disclose Health Information to the Designated Assessment Centre (OCF-14)
Certificate for Attendant Care (OCF-15/59)
Notice of Stoppage of Weekly Benefits and Request for Assessment (OCF-17/59)
Treatment Plan (OCF-18/59)
Application for Determination of Catastrophic Impairment (OCF-19/59)
Assessment of Attendant Care Needs (Form 1)
Since January 1994, Designated Assessment Centres (DACs) have been in place across Ontario for insurance companies and claimants to use when they need a neutral third-party opinion about a claimant's injuries and the accident benefits that apply to those injuries.
DAC's are authorized to conduct independent assessments that are designed to balance the interests of both insurance companies and claimants. Insurers are required to initiate and pay for the cost of the assessment, and the claimant is required to cooperate in the assessment process.
The final report of the DAC is binding, and the insurer must adjust the statutory accident benefits to reflect the DAC findings. If a dispute still exists after the DAC assessment, the parties may use the mediation services at the Ontario Insurance Commission to try to resolve the dispute.
Under the terms of the
Statutory Accident Benefits Schedule (SABS), a committee appointed by the Minister of Finance will establish a roster of qualified independent assessment centres to carry out assessments. These centres are referred to as designated assessment centres or
DACs. The SABS also authorizes the committee to specify the types of impairments that each DAC is authorized to assess and the types of assessments that each DAC is authorized to conduct.
TYPES OF DAC ASSESSMENTS
Under the terms of the SABS, DACs may be authorized to conduct up to four types of assessments. The DAC roster identifies the types of assessments each centre is authorized to conduct for accidents occurring on or after November 1, 1996. DACs may only comment or make recommendations on a current disability status; current attendant care needs, the existence of a catastrophic impairment and proposed medical and rehabilitation goods and services established at the time of the assessment. DACs may not conduct retrospective assessments.
Disability assessments respond to a dispute about the continued payment of weekly benefits. The sole purpose of a disability assessment is to determine whether the claimant, as a result of the accident, continues to be substantially unable to carry on with his or her usual pursuits such as being an income earner, non-earner or caregiver. In making this determination, the assessment must answer: Is the claimant still disabled? Is the disability a result of the automobile accident?
Medical and Rehabilitation Assessments
Medical and rehabilitation assessments deal with questions involving medical expenses, rehabilitation expenses, or both. DACs conducting medical and rehabilitation assessments are responsible for assessing the reasonableness and necessity of proposed medical and rehabilitation goods and services required as a result of the accident. When it is appropriate, they are also responsible for making recommendations for future provision of medical treatment or rehabilitation services required as a result of the accident.
Attendant Care Assessments
Attendant care assessments deal with issues involving attendant care benefits. An attendant care assessment evaluates a claimant's need, as a result of the accident, for attendant services, and to determine the amount of current attendant care benefits.
Catastrophic Impairment Assessments
Catastrophic impairment assessments are designed to determine whether a claimant, as a result of the accident, has sustained a catastrophic impairment using the definition provided in the SABS.
When is a Claimant Referred for a DAC Assessment?
- When the insurance company and the claimant disagree about the claimant's entitlement to a weekly benefit, they must obtain an impartial evaluation conducted by the nearest
DAC listed on the roster that is authorized to assess the claimant's particular impairment, and authorized to conduct disability assessments.
- When the insurance company and the claimant disagree about the claimant's entitlement to a medical or rehabilitation benefit, they must obtain an impartial evaluation conducted by the nearest
DAC listed on the roster that is authorized to assess the claimant's particular impairment, and authorized to conduct medical and rehabilitation assessments.
- When the insurance company and the claimant disagree about the claimant's entitlement to the attendant care benefit or the amount of the benefit, they must obtain an impartial evaluation conducted by the nearest
DAC listed on the roster that is authorized to assess the claimant's particular impairment, and authorized to conduct attendant care assessments.
- When the insurance company and the claimant disagree about whether the claimant's impairment is catastrophic, they must obtain an impartial evaluation conducted by the nearest
DAC listed on the roster that is qualified to assess the claimant's particular impairment, and authorized to conduct catastrophic impairment assessments.
DACs are required to follow these Guidelines when carrying out independent assessments.
These Guidelines have been developed to assist
DACs in carrying out their mandate in a timely, cost-effective manner. The mandate of the assessment centres includes respecting the dignity and ethno cultural individuality of claimants.
The Guidelines provide a broad operating framework to meet the needs of claimants and insurance companies. They leave room for each assessment centre to refine the process to suit individual circumstances.
The Guidelines are intended to complement the text of the SABS. Should a conflict arise between these two documents, the SABS prevails.
The following terms are used throughout this document:
The SABS defines a number of benefits that must be provided to injured parties, depending on the circumstances. The benefits include income replacement, non-earner, caregiver, medical, rehabilitation, and attendant care, death and funeral, and payments for other expenses. Disability assessments deal only with issues relating to weekly income replacement benefits, non-earner benefits, and caregiver benefits. Medical and rehabilitation assessments deal only with issues relating to medical and rehabilitation benefits. Attendant care assessments deal only with issues relating to attendant care benefits. Catastrophic impairment assessments do not deal directly with benefits but provide claimants with access to higher levels of benefits. DACs do not deal with entitlement to death and funeral benefits, transportation expenses, or other pecuniary expenses, such as housekeeping, dependant care or visitor expenses.
The SABS defines "catastrophic impairment" as,
- paraplegia or quadriplegia,
- amputation or other impairment causing the total and permanent loss of use of both arms,
- amputation or other impairment causing the total and permanent loss of use of both an arm and a leg,
- total loss of vision in both eyes,
- brain impairment in respect of an accident that,
- a score of nine or less on the Glasgow Coma Scale, as published in Jennett, B. and Teasdale, G.,
Management of Head Injuries, Contemporary Neurology Series, Volume 20, F.A. Davis Company, Philadelphia, 1981, according to a test administered within a reasonable period of time after the accident by a person trained for that purpose, or
- a score of 2 (vegetative) or 3 (severe disability) on the Glasgow Outcome Scale, as published in Jennett, B. and Bond, M.,
Assessment of Outcome After Severe Brain Damage, Lancet i:480, 1975, according to a test administered more than six months after the accident by a person trained for that purpose,
- subject to subsections (2) and (3), any other impairment or combination of impairments that, in accordance with the American Medical Association's
Guides to the Evaluation of Permanent Impairment, 4th edition, 1993, results in 55 per cent or more impairment of the whole person, or
- subject to subsections (2) and (3), any other impairment that, in accordance with the American Medical Association's
Guides to the Evaluation of Permanent Impairment, 4th edition, 1993, results in a class 4 impairment (marked impairment) or class 5 impairment (extreme impairment) due to mental or behavioural disorder.
A physician, chiropractor, dentist, optometrist, physiotherapist, or psychologist.
The SABS defines "impairment" as a loss or abnormality of a psychological, physiological or anatomical structure or function.
An assessment is requested by an insurance company when the company and a claimant disagree about the claimant's entitlement to a medical or rehabilitation benefit, a weekly benefit, an attendant care benefit, or whether the claimant has a catastrophic impairment. The assessment must be conducted by the nearest DAC to the claimant's residence. When a DAC is not available within 100 km of the claimant's residence to conduct a disability assessment or medical and rehabilitation assessment, the parties may agree to have any qualified individual or facility conduct the assessment. This option does not apply to attendant care assessments or catastrophic impairment assessments. When the parties cannot agree on a qualified assessor, the nearest DAC must be used.
Regulated Health Professional
A member of a College as defined in the
Regulated Health Professions Act, 1991.
Statutory Accident Benefits Schedule, a Regulation made under the
Insurance Act which provide a schedule of no-fault benefits available in Ontario to automobile accident victims.
The SABS includes the following under medical benefits: medical, surgical, dental, optometric, hospital, nursing, ambulance, audiometric speech-language pathology, chiropractic, psychological, occupational therapy and physiotherapy services; medication; prescription eyewear; dentures and other dental devices; hearing aids, wheelchairs, other mobility devices, prostheses, orthotics and other medical devices; transportation for the claimant to and from treatment sessions, including transportation for an aide or attendant; and other goods and services of a medical nature that the claimant requires. Medical and rehabilitation assessments do not apply to prescription eyewear, dentures, other dental devices, and transportation expenses.
The SABS includes the following under rehabilitation benefits: life skills training, family counselling, social rehabilitation counselling, financial counselling, employment counselling, vocational assessments, vocational training, academic training, workplace modifications, workplace devices to accommodate the needs of the claimant, communications aids, home renovations and home devices to accommodate the needs of the claimant, vehicles, and vehicle modifications to accommodate the needs of the claimant.
The health practitioner responsible for co-ordinating and overseeing the claimant's medical treatment and rehabilitation.
Treatment plans provide a description of the goods and services that will be used in the treatment or rehabilitation of a claimant and identify who will provide those goods and services. They must also provide a description of the anticipated benefits from the proposed goods and services, a description of the claimant's impairment and disability, an estimate of the duration of the disability, an estimate of the costs of the goods and services and an estimate of the duration of the services. Treatment plans are to be prepared by a regulated health professional and must also include a statement by a health practitioner indicating that he or she approves of the treatment plan and is of the opinion that the expenses contemplated by the treatment plan are reasonable and necessary. A regulated health professional shall supervise all treatment plans and that person should be identified in the plan.
In keeping with the aim of respecting a claimant's dignity and ethnocultural individuality, and of ensuring that the assessment process remains independent and free of bias, regulated health professionals involved in DAC assessments are required to adhere to the confidentiality and conflict of interest policies of their respective regulatory professional Colleges. Some DACs may also be governed by the
Public Hospitals Act.
In addition, each DAC is required to establish confidentiality policies for its staff.
CONFLICT OF INTEREST
To ensure that the assessment process remains independent and free of bias, the SABS provides conflict of interest rules for
DACs. Assessment centres are responsible for establishing procedures to ensure that conflicts of interest are identified early in the process. When a conflict of interest exists, the DACs must ensure that they are declared and resolved satisfactorily. DACS must adhere to the conflict of interest rules in section 53 of SABS.
The existence of a conflict of interest does not mean that the assessment in question can not be provided objectively and impartially, and the rules are not intended to penalize a DAC for declaring a conflict of interest. Rather, the purpose is to support and encourage honest, ethical behaviour.
The SABS state that a DAC has a conflict of interest relating to an assessment if,
1. the insurance company, the claimant or a lawyer acting on behalf of the insurance company or the claimant has a financial interest in the DAC; or
2. the DAC, a related person or a facility owned or controlled, directly or indirectly, in whole or in part, by the centre or a related person,
(i) has provided goods or services to the person to be assessed, other than a previous DAC assessment,
(ii) prepared or approved a treatment plan for the person to be assessed, or
(iii) is identified by a treatment plan as a person who will provide goods or services to the person to be assessed.
Related person means an owner of, employee of, partner in, business associate of or consultant retained by the DAC.
In addition to identifying and resolving direct conflicts of interest outlined in the SABS,
DACs are required to establish procedures to enable them to identify conflicts of interest. DACS must also establish procedures to enable them to monitor and deal with situations where the assessment centre, its staff or members of the assessment team contracted by the centre, may receive a non-financial benefit by providing particular goods or services to a claimant.
Regulated health professionals involved in DAC assessments are also governed by the conflict of interest rules of their respective regulatory professional Colleges.
DAC is responsible for establishing whether or not there is a conflict of interest.
After receiving the referral, the
DAC should review the material for any conflict of interest. The
DAC will declare in writing to the insurance company and the claimant the nature of any conflict that arises prior to an assessment.
On receiving the written conflict of interest declaration, the insurance company and the claimant, acting in good faith, are to agree to use a facility that both parties believe will result in an objective, impartial assessment. This may be the original DAC, if it is felt that the declared conflict of interest will not interfere with the assessment. As an alternative, the referral can be directed to the next nearest suitable
DAC, or in the case of a disability or medical and rehabilitation assessment, any other qualified person or facility if a DAC is not available within 100 km of the claimant's residence.
If the insurance company and the claimant cannot agree, the original DAC will be informed by the insurance company and the referral information will be returned immediately to the insurance company. The insurance company must then arrange, at its expense, to refer the claimant to the next nearest
DAC that is qualified to assess the claimant.
Future Assessments and Treatment
The conflict of interest rules do not prevent a
DAC from providing a future re-assessment as part of the DAC process.
The SABS state that a DAC cannot provide treatment to a claimant in respect of the automobile accident after the claimant has been assessed at that DAC. The only exception is where the claimant and the insurer both agree to use the DAC for treatment or where there is no other provider within 50 kilometres of the claimant's residence who can provide the goods or services.
THE ASSESSMENT PROCESS
Assessments are to be conducted in a timely, cost-effective manner, respecting the claimant's dignity and ethno cultural individuality.
The assessment process itself is broken down into four distinct components or stages:
Stage 1: Referral
Stage 2: Intake
Stage 3: Assessment
Stage 4: Reporting
Each DAC should have health professionals and other experts, specifically identified on the DAC team roster filed with the OIC, to conduct assessments. To ensure that the health professionals are well-qualified, they should have a minimum of three years of related experience in their particular field. DACs may not use assessors that have not been filed with the OIC.
To ensure that assessments are completed in a cost-effective manner with a minimum of inconvenience to claimants, a mechanism should be established for tracking each claimant through the assessment process. This is particularly important when several health professionals are involved in a multi-disciplinary team assessment. To facilitate this, assessment centres are encouraged to appoint a case coordinator to assume responsibility for ensuring that the process proceeds smoothly. The coordinator may be a clinician on the assessment team, or a DAC support staff.
Continuation of Benefits
In some instances, when an independent assessment is initiated, insurers are required to continue paying the benefit in question during the assessment period. In other instances, they are not required to pay the expense until the assessment is completed which means that the claimant may not be receiving treatment. In either case, both parties are relying on the DAC to provide an opinion. This holds true whether the independent assessment is conducted by a DAC or any other qualified individual or facility mutually agreed upon if a DAC is not within 100 km of the claimant's residence. For this reason, assessments must be completed in a timely manner.
If a claimant fails to attend a scheduled appointment or to participate in or complete the assessment, the insurer must be informed by the DAC immediately. The insurance company may then initiate stoppage of benefits in accordance with the SABS.
The Disability Assessment Process
Disability assessments are designed to determine whether a claimant, as a result of the accident, continues to suffer substantial inability to carry on with his or her normal daily activities. To reach this determination, they focus on: Is the claimant still disabled? Is the disability a result of the automobile accident?
Disability assessments do not deal with treatment issues, providing a prognosis for recovery or the amount of benefits. Disability assessments shall take into consideration accommodations funded by the insurer that allow the claimant to carry out his or her normal daily activities.
DACs that are authorized to evaluate disabilities may only be authorized to conduct such assessments in a specific range of impairments -- musculo-skeletal, brain, spinal cord and psychological impairments.
The Medical and Rehabilitation Assessment Process
Medical and rehabilitation assessments involve a range of assessment and diagnostic procedures to:
- Determine whether, as a result of the accident, the proposed treatment plan is reasonable and necessary, and
- Recommend future provision of medical treatment, or rehabilitation services, or both, necessary to help the claimant recover from an impairment following an automobile accident.
The Attendant Care Assessment Process
Attendant care assessments are designed to determine whether claimants who have physical, psychological or mental impairments as a result of automobile accidents require attendant services. The assessment establishes the amount of a global monthly benefit available to the claimant for the purpose of purchasing attendant services, or of compensating family members providing services, or a combination of the two.
The questions posed to DACs conducting attendant care assessments focus on two issues:
- As a result of the accident, the level of attendant services and the amount of the attendant care benefit required at the time of the assessment to provide the claimant with assistance with both personal care and the tasks of daily living.
- As a result of the accident, the level of attendant services and the amount of the attendant care benefit required at the time of the assessment to enable the claimant to live independently at home.
Attendant care assessments do not deal with evaluating a claimant's continuing treatment or rehabilitation needs. Attendant care assessments must be conducted in the claimant's residence.
The Catastrophic Impairment Assessment Process
Catastrophic impairment assessments are designed to determine whether the physical, psychological or mental impairments that a claimant has sustained as a result of the accident are catastrophic. Catastrophic impairment assessments do not deal with treatment issues or the amount of benefits.
The assessment establishes:
- whether the claimant's brain impairment, based on a review of medical/hospital records, scored a nine or less on the Glasgow Coma Scale;
- whether the claimant's impairment scores 2 (vegetative) or 3 (severe disability) on the Glasgow Outcome Scale;
- whether the claimant's impairments results in 55 per cent or more impairment of the whole person in accordance with the American Medical Association's
Guides to the Evaluation of Permanent Impairment, 4th edition, 1993; or
- whether claimant's impairment results in a class 4 impairment (marked impairment) or class 5 impairment (extreme impairment) due to mental or behavioural disorder in accordance with the American Medical Association's
Guides to the Evaluation of Permanent Impairment, 4th edition, 1993.
The mandate of the DACs limits addressing issues of causation to those necessary in answering the referral question.
STAGE ONE: REFERRAL
Initiating a Referral
All referrals to a DAC are to be made by an insurance company. In many cases the request for an assessment may be initiated by the claimant, however, the actual referral must be made by the claimant's insurer.
In order to assess the need to continue paying weekly benefits, insurance companies are entitled to ask claimants to provide an up-to-date
Disability Certificate (OCF 3/59) from their treating practitioner, and ask claimants to be examined by a professional chosen by the insurer. However, if the insurer determines that the claimant no longer suffers from a disability as a result of the automobile accident, the insurer will notify the claimant that the weekly benefits will be stopped and that the claimant can request a disability assessment at a DAC. A referral to a DAC for a disability assessment will only be made when the claimant has requested such an assessment.
Medical and Rehabilitation Assessments
An insurance company can require a claimant to submit a treatment plan (Treatment Plan (OCF-18/59) before incurring any expenses for medical and rehabilitation goods or services. Within 14 days of receiving a treatment plan, the insurer will notify the claimant whether it approves all, part or none of the treatment plan. If insurer does not approve all of the treatment plan, the insurer must refer the claimant to a DAC that is authorized to conduct medical and rehabilitation assessments. The claimant can choose to abandon their claimant or submit a revised plan rather than undergo the DAC assessment. The only exception is 15 treatment sessions with a chiropractor or physiotherapist within the first six weeks after the accident. These expenses msut also be included in a Treatment Plan, but can be incurred during the period the insurer reviews the Plan.
No DAC referral is required with respect to:
Attendant Care Assessments
- devices partially covered by the Ministry of Health's Assistive Device Program
- prescription eyewear, hearing aids, dentures, or other dental devices
- expenses for transportation to or from treatment or rehabilitation sessions
- disputed vocational rehabilitation expenses that may be payable by the WCB
- treatment plans submitted after incurring any expenses for medical and rehabilitation goods or services
In order to assess the need to continue paying attendant care benefits, insurance companies are entitled to ask claimants to provide a
Certificate for Attendant Care (OCF-15/59) from their treating practitioner. The certificate will confirm what attendant services a claimant needs as a result of an the automobile accident for which the benefits are being paid.
Catastrophic Impairment Assessments
When a claimant and an insurance company disagree over the claimant's need for attendant care services or the amount of the benefit, either of the two may request that the issue be referred to the nearest DAC authorized to conduct attendant care assessments.
A claimant may request that their insurance company determine whether the impairments sustained in an accident are catastrophic. The claimant will submit an
Application for Determination of Catastrophic Impairment (OCF-19/59) form to the insurance company to initiate the process. In order to assess catastrophic impairment, insurance companies are entitled to ask claimants to provide up-to-date reports or documentation from their treating practitioner regarding diagnosis and prognosis of impairments resulting from the automobile accident for which benefits are being paid.
The insurer must decide, within 30 days of receiving a request from a claimant, if the impairment is catastrophic, and inform the claimant of its decision. The insurer may agree with the request, decline the request, or ask that the claimant be assessed by the nearest DAC authorized to conduct catastrophic impairment assessments. In addition, if the insurer declines the claimant's request, the claimant can ask to be assessed by a DAC.
A referral to a DAC must be made within 15 days of any of the above situations that lead to the DAC assessment request. The referral must be made to the nearest
DAC listed on the roster that is qualified to conduct the requested assessment. If the request is for a disability assessment or medical and rehabilitation assessment and there is no DAC within 100 km of the claimant's residence, then the insurance company and the claimant can agree for the evaluation to be conducted by any qualified individual or facility within the 100 km area. This does not apply to attendant care assessments and catastrophic impairment assessments.
If the insurer and the claimant can not agree on a qualified individual or facility within the 100 km area, the assessment must be conducted by the nearest qualified DAC on the roster. The DAC roster indicates the types of assessments that each DAC is authorized to conduct and the types of impairments that each DAC is authorized to assess.
"Nearest" refers to the distance from a DAC facility to the claimant's residence. Insurers should refer to the DAC Maps for assistance in determining the "nearest" DAC.
Responsibilities of the Insurer
SABS requires the insurer to explain to the claimant how the DAC process works.
- The insurer must confirm that the claimant agrees to participate in the DAC referral, and signs all approved release forms for medical documentation that will be included in the DAC referral package.
- The insurer must also inform the claimant of its policy regarding missed or cancelled appointments if the claimant does not provide the DAC with appropriate notification of a need to cancel an appointment.
- The insurer must notify the DAC, in writing, to initiate an assessment request. As the first step in the assessment, this notification, in the form of a referral, sets the stage for the entire process. To ensure a successful outcome, the DAC must receive a complete referral, including a signed
Permission to Disclose Health Information to the Designated Assessment Centre (OCF-14) form and up-to-date medical documentation and reports. A list of the referral package elements is included in this guideline (see page 15).
- The insurer must inform the
DAC of any possible security issues or problems that may be encountered in scheduling or conducting the assessment.
When a referral is made, the insurance company fills out the appropriate section of the
Designated Assessment Referral and Summary Report (OCF-11) form. This form is not required for attendant care assessment referrals. Instead, the insurance company completes the appropriate section of the
Assessment of Attendant Care Needs (Form 1). The OCF-11 form provides a synopsis of the relevant case information. It is submitted with the written referral request; accompanies the claimant's file through the assessment process; and is sent to the insurance company, the claimant and the claimant's treating practitioner with the report. The form includes a summary of the criteria to be used when assessing disability. To avoid delays at this stage of the process, insurance companies are encouraged to confirm that all relevant and up-to-date information is submitted to the
DAC along with the
Designated Assessment Referral and Summary Report (OCF-11) form or the
Assessment of Attendant Care Needs (Form 1).
SABS requires complete disclosure of all relevant information necessary to complete the assessment. While the insurance company and the claimant share responsibility for supplying this information, the insurance company is responsible for ensuring that all elements in the referral package are received by the DAC prior to the assessment appointment.
Permission to Disclose Health Information to the Designated Assessment Centre (OCF-14) form, with an original signature by the claimant, must be submitted with the referral package. A DAC can not commence an assessment without receiving a completed and signed OCF-14 form.
SABS sets out a strict time frame for completing the referral stage of the assessment process. Once the independent assessment process is initiated, the insurance company is required to prepare and transmit the written referral and notify the appropriate assessment centre within 15 days.
The SABS requires complete disclosure of all relevant up-to-date information necessary to complete the assessment.
The following items are to be included (when relevant) in a DAC referral package:
Designated Assessment Referral and Summary Report (OCF-11/59) form
Assessment of Attendant Care Needs (Form 1) (attendant care assessments only)
Permission to Disclose Health Information to the Designated Assessment Centre (OCF-14) form, signed by the claimant
Notice of Stoppage of Weekly Benefits and Request for Assessment (OCF-17/59) (disability assessments only)
4. ___ recent
Disability Certificate (OCF-3/59) (disability assessments only)
___ completed Treatment Plan (OCF-18/59) including a clear statement from the insurer indicating which goods or services are being disputed (medical and rehabilitation assessments only)
Certificate for Attendant Care (OCF-15/59) (attendant care assessments only)
Application for Determination of Catastrophic Impairment (OCF-19/59) form, completed by a health practitioner including details of the claimant's catastrophic impairment (catastrophic impairment assessments only)
5. ___ summary of treatment and services received to date
6. ___ Details of applicable activities
___ job analysis
___ new occupation
___ recommended occupation
___ care giving activities
___ normal life activities
7. ___ health professional's or hospital reports
8. ___ insurer examination reports
9. ___ functional capacity evaluation/physical capacity assessment reports
10. ___ consultant reports
11. ___ vocational testing reports
12. ___ case management reports
13. ___ brief description of the accident
14. ___ claimant's current complaints
15. ___ list of medications
16. ___ special needs, if any (including language requirements, mobility/access requirements, other precautions)
17. ___ other relevant information
18. ___ list of documents contained in the referral package
Failure to include up-to-date medical documentation or other elements in the referral package that are required by the DAC in order to conduct the assessment, may result in the assessment being delayed until the information is received by the DAC.
STAGE TWO: INTAKE
This stage of the assessment begins when the
DAC receives the referral in writing. It may be forwarded by mail, courier or fax. If it is forwarded by fax, the insurance company and the
DAC must ensure, before transmission, that the confidentiality of the information in the referral package is secured.
DAC Intake Responsibilities
At the intake stage, the assessment centre is expected to do the following:
Date: Record the date the referral is received. Because time frames for completing various phases of the process have been established, this detail is particularly important.
Permission to Disclose Health Information to the Designated Assessment Centre (OCF-14) Form: Ensure that the referral package includes a
Permission to Disclose Health Information to the Designated Assessment Centre (OCF-14) form with an original signature by the claimant authorizing the release of information. The referral is not complete until this signed form is received by the DAC.
Conflict of Interest: Determine whether a conflict of interest exists. If the answer is yes, the conflict must be declared and resolved according to the conflict of interest rules in the SABS and included in this document (see page 6).
Complete and Accurate Referral Package: Ensure that the information in the referral package is complete, up-to-date and accurate. If information is missing, the insurance company or the claimant must be notified quickly and asked to provide it. The referral package must contain either the
Designated Assessment Referral and Summary Report (OCF-11/59) form or the
Assessment of Attendant Care Needs (Form 1) since the assessment centre will use these forms to report back to the insurer and claimant.
In rare instances, with the consent of the insurance company and the claimant, the assessment centre may assume responsibility for gathering information directly. However, in such instances, the DAC will be responsible for any delays resulting from incomplete referral information.
Referral Question: Ensure that the referral is appropriate and that the referral question is clearly defined. If clarification is required, consult the insurance company.
Assessment of DAC Resources: Assess whether the facility is authorized to conduct the requested assessment and has the necessary professional and other resources to assess the claimant's impairment. If not, the centre must notify the insurance company and the claimant that the question must be referred to another
DAC. This is particularly important with brain, spinal cord and psychological impairments. If a team approach is indicated, identify a primary assessor as the team leader. Members of an assessment team are to be selected on the basis of their professional ability to respond to the referral question. For example, if the question relates to chiropractic issues, a chiropractor shall be included on the assessment team.
Intake Interview: If necessary at this point, the
DAC may conduct a preliminary telephone interview to ensure that the claimant is aware of the referral, understands the purpose and scope of the assessment, and to elicit a brief history that might extract any other missing information in the referral package.
Confirm Essential Duties: If the DAC is conducting a disability assessment, it will be necessary to confirm with the claimant his or her essential duties. To carry out a successful disability assessment, DACs must have a clear description of the claimant's essential tasks. This information is provided as part of the referral package. Where these are not defined completely or are in dispute, the DAC is responsible for undertaking the analysis necessary to clarify outstanding issues before starting the assessment stage of the process. DACs should have the appropriate professionals to do a task analysis. The applicable disability tests are found on the
Designated Assessment Referral and Summary Report (OCF-11/59) form.
Review and Clarify: If necessary, organize a meeting of the assessment team to review the claimant's file and clarify what the assessment is designed to achieve and how this will be accomplished.
Diagnostic Procedures: Identify any further diagnostic procedures, investigations and consultations required to complete the assessment.
Special Needs: Determine whether the claimant has special needs. For example, assessment centres are responsible for providing an interpreter for claimants who do not speak English, and for ensuring that facilities are readily accessible to disabled claimants.
Assessment Plan: Prepare a written assessment plan.
Insurer Approval: Notify the insurance company of details of the proposed assessment plan, fees and assessment costs, and the projected time to complete the assessment. The insurance company may not specify who should be involved in the assessment. Receive approval from the insurance company to proceed. Under the
Health Insurance Act, costs related to DAC assessments are not insured services. All aspects of independent assessments, including diagnostic tests conducted, must be paid by the insurer.
At this point, the insurance company may choose not to proceed with the assessment, opting instead to continue paying the benefit in question. An assessment plan can only be accepted in its entirety.
Claimant Consent: Notify the claimant of details of the proposed assessment. Ensure that the claimant understands both the reason for the referral and the assessment process itself, including the purpose of the DAC report. The claimant may not specify who should conduct the assessment. Ensure that the claimant will co-operate with the assessment. If the claimant will not co-operate, or agree to the assessment, notify the insurance company immediately.
Appointments: Schedule appointments in consultation with the claimant not more than 2 weeks from the date when the referral information is complete. When the assessment involves more than one health professional, every effort should be made to schedule appointments at a single location at convenient times for the claimant.
Claimants should be advised by the
DACs that they may be responsible for the cost of an appointment if they fail to attend or provide sufficient notice that they are unable to attend.
DACs should attempt to contact claimants 48 hours before an appointment to confirm attendance. If a claimant cannot be reached, the insurance company is to be notified and asked to assist in contacting the claimant.
STAGE THREE: ASSESSMENT
In all cases, the assessment focuses on addressing the specific referral question:
- Does the claimant continue to suffer from the disability?
- Are the goods and services recommended in the claimant's treatment plan reasonable and necessary for the claimant's treatment or rehabilitation?
Form 1, what amount of attendant care benefit should be paid to the claimant?
- Are the claimant's impairments catastrophic?
Disability assessments shall take into consideration accommodations funded by the insurer that allow the claimant to carry out his or her normal daily activities.
The SABS requires assessors to use the form,
Assessment of Attendant Care Needs
(Form 1) when conducting attendant care assessments. Its purpose is to determine the level of attendant services and the amount of the attendant care benefit required by the claimant. Attendant case assessments must be conducted in the claimant's residence.
During the assessment stage of the process, each health professional is expected to do the following:
Review: Review the referral package information.
Explanation to Claimant: Discuss with the claimant the reason for particular procedures, and make clear that all relevant information received from the claimant will be included in the assessment report.
Claimant Input: Provide claimants with adequate opportunity to contribute to the examination, and explain any continuing problems they may be experiencing.
Family Involvement: In the case of attendant care assessments, involve family members in the evaluation when necessary.
Case Conference: Participate in a case conference to draw together the findings of the various health professionals in preparation for writing a summary, when necessary.
DAC Report: Include all relevant findings in a signed, written comprehensive DAC report. When a team approach is involved, reports completed by individual assessors will be integrated into and appended to a summary prepared by the primary assessor and included in the DAC report. In the case of attendant care assessments, it is only necessary to complete the
Assessment of Attendant Care Needs (Form 1).
SABS specify that a DAC must begin the assessment with 14 days after receiving the assessment referral from an insurer. A DAC is not considered to have received a referral until a complete referral package has been received. If a DAC is unable to begin an assessment within 14 days, the claimant and insurer must be informed. The claimant or insurer can require that the assessment be referred to the next nearest DAC.
STAGE FOUR: REPORTING
For each claimant, the DAC is required to produce a written, final report. This will be prepared and signed by the professional designated as the primary assessor and includes the signature of each team member involved in the assessment. At this stage, the
DAC is responsible for filling in the relevant sections of the
Designated Assessment Referral and Summary Report (OCF-11/59) form and including it with the written DAC report. These sections, which must be completed by the primary assessor, include a synopsis of the
DAC's definitive response to the referral questions.
The only exceptions are attendant care assessments. For each claimant, the DAC is required to complete an
Assessment of Attendant Care Needs (Form 1). This completed form constitutes the DAC report.
Content Of The DAC Report
All DAC reports other than those involving attendant care assessments should include the following:
Dates: Date(s) the claimant was assessed by each health professional on the team. Date the report was completed.
Summary: A summary of the findings of the assessment. This must respond directly to the question or questions posed by the insurance company in the referral, and provide a definitive opinion.
With respect to disability assessments, providing a percentage of disability is not within the scope of the
SABS. It is within the scope of the SABS to report percentage of impairment if the DAC is conducting a catastrophic impairment assessment. DACs do not provide a prognosis for recovery with the exception of catastrophic impairment assessments where it may be necessary to comment on whether the claimant's condition has stabilized and is likely to improve with further treatment.
It is the responsibility of DACs conducting medical and rehabilitation assessments to comment on, or make recommendations about, the reasonableness of the goods and/or services in dispute, including their expense. In addition, DACs can comment on the reasonableness of fees as they relate to treatment. The opinion provided should take into account any applicable professional fee guidelines published by the Ontario Insurance Commission.
It is the responsibility of DACs conducting attendant care assessments to determine the amount to be paid for the provision of attendant care services. The monthly amount will be determined in accordance with Form 1 under the SABS.
List: When a team approach is involved, the report includes a list of the attached reports from the individual health professionals who formed part of the assessment team.
Signatures: The signature of the primary assessor who prepared the summary and the final DAC report. To indicate that they have read it, the health professionals involved in the assessment should also sign the summary report.
Style and Language
The report is designed to be useful to individuals who in most cases, don't have a medical background. To ensure that it is legible, readable and understandable, it should be typed in language that is clear and free of jargon and medical terms. When it is necessary to use a medical term, the term should be carefully explained.
ProvidersDACs are prohibited from recommending specific providers, either for treatment or rehabilitation services, as it is outside the mandate of DACs.
The SABS state that a DAC cannot accept patients for treatment or rehabilitation for injuries sustained in the automobile accident for which the person was seen by the facility as part of a DAC assessment. Please refer to the conflict of interest rules (see page 6).
In some cases, the health professionals involved in an assessment may discover issues that are beyond the scope of the assessment, but which nevertheless, affect the claimant's health. When this happens, these findings, and the recommendations stemming from them, should not be raised in the assessment report. Rather, the assessor involved should discuss or report separately in writing to the claimant and/or the treating practitioner.
SABS, copies of the complete DAC report must be submitted to the insurance company, the claimant and the claimant's treating practitioner.
With appropriate authorization from the claimant, the
DAC may distribute the report and the records associated with it to third parties.
Although no specific time frame is set out in the
SABS, the report should be prepared and distributed within 14 days of completion of the assessment stage of the process.
DACs are responsible for storing and archiving assessment records for a minimum of seven years or for the minimum period established by the various regulating professional Colleges or
Public Hospitals Act, in the case of hospitals, whichever is greater.
Monitoring and Evaluation
The successful outcome of the assessment process introduced in the
SABS depends, to a great extent, on the quality of the assessments conducted by
DACs. To demonstrate a commitment to providing an impartial, objective service that is valuable to both claimants and insurance companies,
DACs are encouraged to review their performance by establishing follow-up procedures for monitoring and evaluating the effectiveness of their reports and recommendations.
DACs are expected to provide the Ontario Insurance Commission with data on a regular basis and participate in other monitoring and evaluation activities.
For additional information about the
SABS, this document or the assessment process, contact:
Ontario Insurance Commission
5160 Yonge Street
Toronto, Ontario M2N 6L9
(416) 250-7250 or 1-800-668-0128
Fax: (416) 590-7070