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Insurance Act

ONTARIO REGULATION 89/14

SERVICE PROVIDERS — LISTED EXPENSES

Consolidation Period:  From December 1, 2014 to the e-Laws currency date.

Last amendment: O. Reg. 229/14.

This is the English version of a bilingual regulation.

Definitions

1. In this Regulation,

“Guideline” means a Guideline referred to in subsection 49 (3) of the Statutory Accident Benefits Schedule; (“directive”)

“settlement” has the same meaning as in subsection 9.1 (1) of Regulation 664 of the Revised Regulations of Ontario, 1990 (Automobile Insurance) made under the Act; (“règlement”)

“Statutory Accident Benefits Schedule” means Ontario Regulation 34/10 (Statutory Accident Benefits Schedule — Effective September 1, 2010) made under the Act. (“annexe sur les indemnités d’accident légales”) O. Reg. 89/14, s. 1; O. Reg. 229/14, s. 1.

Listed expenses, s. 288.1 (1) of the Act

2. (1) For the purposes of paragraph 1 of subsection 288.1 (1) of the Act, the following are the prescribed assessments, examinations, reports, forms or plans referred to in that paragraph:

1. The assessments, examinations, reports, forms or plans that are specified in a Guideline in the circumstances specified in the Guideline.

2. A disability certificate referred to in paragraph 2 of section 66 of the Statutory Accident Benefits Schedule, if an invoice in respect of the certificate is submitted to a central processing agency referred to in subsection 49 (3) of the Statutory Accident Benefits Schedule instead of to an insurer. O. Reg. 89/14, s. 2 (1).

(2) For the purposes of paragraph 2 of subsection 288.1 (1) of the Act, the prescribed goods and services are those goods and services that are specified in a Guideline. O. Reg. 89/14, s. 2 (2).

Exception, s. 288.1 (2) of the Act

2.1 Amounts payable that have been approved by an insurer in accordance with the Statutory Accident Benefits Schedule that would otherwise be listed expenses are not listed expenses if the following circumstances exist:

1. There is a settlement between an insurer and an insured person that includes or otherwise provides for the approved amounts.

2. The requirements of section 9.1 of Regulation 664 of the Revised Regulations of Ontario, 1990 (Automobile Insurance) made under the Act have been met with respect to the settlement.

3. The settlement has not been rescinded under subsection 9.1 (4) or (5) of Regulation 664 of the Revised Regulations of Ontario, 1990. O. Reg. 229/14, s. 2.

Payment for listed expenses, s. 288.2 of the Act

3. (1) An insurer is prevented by subsection 288.2 (1) of the Act from making a payment for a listed expense to a person or entity unless the person or entity held a service provider’s licence on both of the following dates:

1. The date recorded on the invoice as the date of service in respect of the assessment, examination, report, form, plan, good or service to which the listed expense relates.

2. The date on which the invoice in respect of the listed expense was received by the central processing agency referred to in subsection 49 (3) of the Statutory Accident Benefits Schedule. O. Reg. 89/14, s. 3 (1).

(2) Despite subsection (1), an insurer is not prevented from making a payment for a listed expense to a person or entity if all of the following circumstances exist:

1. The person or entity held a service provider’s licence on the date on which the invoice in respect of the listed expense was received by the central processing agency referred to in subsection 49 (3) of the Statutory Accident Benefits Schedule.

2. The person or entity requests payment of the listed expense because of an acquisition, amalgamation or transfer involving another person or entity and,

i. the other person or entity provided the assessment, examination, report, form, plan, good or service to which the listed expense relates, and

ii. the other person or entity has not requested or received payment of the listed expense.

3. The person or entity that provided the assessment, examination, report, form, plan, good or service held a service provider’s licence on the date recorded on the invoice as the date of service in respect of that assessment, examination, report, form, plan, good or service. O. Reg. 89/14, s. 3 (2).

(3) The restriction imposed under subsection 288.2 (1) of the Act does not apply with respect to a listed expense if the date of service recorded on the invoice in respect of the assessment, examination, report, form, plan, good or service to which the listed expense relates is before the date on which section 288.2 of the Act comes into force. O. Reg. 89/14, s. 3 (3).

4. Omitted (provides for coming into force of provisions of this Regulation). O. Reg. 89/14, s. 4.

 

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