When the insured party survives a car collision but requires treatments, the insurance policy provides for medical coverage. The treatments covered are defined as follows in the contract:
- The insurer will pay with respect to each insured person who sustains a bodily injury as a result of an accident reasonable expenses resulting from the accident within the benefit period set out in clause
- Category 1: necessary medical, surgical, dental, chiropractic, ambulance, hospital, or professional nursing services;
- Category 2: any other necessary service within the meaning of entitled services in the Hospital Services Act or the Medical Services Payment Act; and
- Category 3: other goods and services, which, in the opinion of the insured person’s attending physician and in the opinion of the insurer’s medical advisor, are essential for the treatment, occupational retraining or rehabilitation of the insured person.
- Medical services mentioned in subclause (a) of clause (1) means services;
- Performed by a physician, or
- Performed by a duly qualified health professional and prescribed by a physician as necessary for the treatment of the person.
Medical Coverage – Category 1 & 2
The New Brunswick Court of Appeal has been called upon to address the scope of the treatments covered in case where the insurer refused to cover massage therapy services: Rolfe v. Axa Insurance Co., 2004 NBCA 14. The unanimous bench concluded that ‘medical services’ has an expansive meaning which extends to massage therapy and were thus a category 1 expense. This determination is of consequence as the insurer’s medical advisor has no say for the payment of those expenses (paras 6-8 & 68; Webb v. Aviva Insurance Co., 2011 NBQB 98 para 22). Although not part of the ratio in Rolfe, supra, the unanimous bench also recognized “that expenses incidental to the procurement of Subsection 1(1) services, such as the cost of related meals, lodging and transportation, are covered” (para 25). Physiotherapy services are a category 1 medical service: Lamrock v. Wellington Insurance Co. (1999), 222 NBR (2d) 374 para 13-16 (QB). The insurer may require credentials for the professionals providing services: Davidson v. Medavie Blue Cross, 2011 NBQB 378 paras 17-20. Babysitting and Household cleaning services are not a category 1 expense, even if prescribed by a physician: Solomon v. Portage La Prairie Mutual Insurance Co., 1993 CanLII 8205 para 6 (QB). Furthermore, expenses for medical assessments incurred by the insured without the knowledge and approval of the insurer, to advance a claim against a third part, are not captured by the provision even if of a category 1: Veno v. United General Insurance Corp., 2008 NBCA 39 para 91.
Medical Coverage – Category 3
Regarding the other ‘goods and services’ (category 3), covered on the advice of the attending physician and the insurer’s medical advisor, the provision is not expressly limited to the medical elements. Although a treadmill was disallowed in Veno, supra, because the attending physician and medical advisor deemed it unnecessary, it likely would have been an admissible expense otherwise. In Solomon, supra para 6, Justice Godin expressed the opinion, in addition to babysitting and housecleaning services not being “prescription expenses”, that they were neither “legitimate expenses”. Hence, a court may be inclined to view such services as not “essential for the treatment, occupational retraining, or rehabilitation of the insured person.” The unanimous Court of Appeal has also refused to consider college tuition as a legitimate category 3 retraining or rehabilitation expense: Joynes v. Canadian Home Insurance Co. (1989), 96 NBR (2d) 433 (CA).
Although the insurance contract provides that only category 3 medical expenses are payable on the advice of the attending physician and the insurer’s medical advisor.