Section B: Medical Expenses

Section B: Medical Expenses

Have you been injured in a motor vehicle accident and do you require medical treatment, but you can’t afford to pay for it on your own? No problem. It’s highly likely that your auto insurance company will cover the entire cost of your treatment.

Under Section B of the Standard Automobile Policy for New Brunswick, your auto insurer has an obligation to reimburse you for the costs of medical treatment if your doctor deems this treatment necessary to your recovery. These benefits cover all reasonable medical expenses incurred within four years of the accident, up to a maximum of $50,000.00.

Whether you are a driver, passenger, cyclist, or pedestrian injured in a motor vehicle accident, you are probably covered under the Section B provisions applicable to the vehicle you were driving or were a passenger in, or the vehicle that struck you. And don’t worry: even if you are responsible for the accident, you are still eligible for benefits under Section B. 

Although this blog post focuses on the issue of Section B medical expenses, if you’re looking for more information about other benefits available under Section B (including compensation for lost income), read the following blog post.

Initiating a claim

To ensure that your medical treatment is covered by your Section B insurer, you need to follow certain preliminary steps, including the following:

  1. Advise the insurer: You must contact the Section B insurer liable for covering your medical expenses within 30 days of the date of the accident, or as soon as possible thereafter. If you are unsure who the appropriate Section B insurer is, contact Fidelis Law Droit right away so that our lawyers can help you determine this.
  2. Complete forms: After you contact your Section B insurer, a claims adjuster will be appointed to administer your claim. Your adjuster will then send you three forms: one for you, one for your doctor and one for your employer. You have to return these forms to your insurer within 90 days of the date of the accident. If you are having any challenges completing your forms, contact your lawyer at Fidelis Law Droit right away.

What next?

Sometimes, the Section B insurer authorizes your health care professionals to bill your insurer directly for their services. In other cases, Section B insurers require you to pay for the cost of your treatment up front and then submit all receipts for reimbursement. Keep in mind that your Section B insurer has 30 days to issue reimbursements. If it’s taking too long for you to receive your reimbursement, don’t wait: contact your lawyer at Fidelis Law Droit without delay to ensure that your rights are being respected.

Know your rights

Initiating a Section B claim is usually a straightforward process, and your adjuster may certainly be very courteous and helpful. However, a careful appreciation of your rights is warranted during this period of vulnerability. This vulnerability comes from the imbalance of power between the insured and the insurer in the claim process. The insured is vulnerable to the insurer’s conduct because he or she needs timely access to benefits payable as a result of an accident. The insured is essentially at the mercy of the insurance adjuster during this process. If you feel you are not properly treated and are not receiving benefits you should be receiving, you have the right to obtain legal advice from a lawyer.

The duty of good faith that governs the claim adjudication relation between insured and insurer attempts to alleviate and minimize the risk of power imbalance between the parties by creating a risk of significant penalties in the form of punitive and aggravated damages awarded against a faulty insurer.

The imbalance of power between the insured and the insurer is a concept that has been highlighted many times by the courts. In fact, in Walsh v. Nicholls, 2004 NBCA 59, Chief Justice Drapeau (as he then was) of the New Brunswick Court of Appeal, stated the following at paragraph 35:

In processing claims for no-fault auto insurance benefits, the insured is particularly at the mercy of the adjuster; indeed, most insured are unfamiliar with the pertinent terms of the Policy and accept at face value the adjuster’s delineation of coverage and determination of entitlement. Moreover, the financial stakes are seldom significant, and adjusters know full well that very few insured will go to the expense of retaining a lawyer to challenge the rejection of their claims. In short, the context is fecund ground for abuse by the unscrupulous; in my view, tort law must step into the fray and do its share to discourage abuse of power on the part of adjusters.

You may trust their decision to deny you coverage, but you should speak with one of our lawyers if you feel like your entitlement to benefits has been wrongfully denied.

Hardball tactics frequently used by insurers

As Chief Justice Drapeau put it, unscrupulous adjusters find “fecund ground” to abuse your rights when the opportunity arises to do so. These hardball tactics on the part of adjusters can vary widely.

For example, your adjuster may inform you that direct billing is only available through certain providers. This tactic is problematic for two reasons: 1) your insurer is taking advantage of your financial vulnerability to ensure that you choose certain health care professionals whose terms are more favourable to it; and 2) your insurer is trying to take charge of your recovery plan despite the fact that it has no medical expertise.

Remember, it’s not up to your adjuster to decide where you need to go for treatment or what type of treatment would be most beneficial for your recovery. It’s up to your doctor to choose the appropriate treatment approach for your condition, and the choice of health care professionals is up to you. As Justice Grant stated in paragraphs 21 and 22 of Webb v. Aviva Insurance Co., 2011 NBBR 98, in which the issue was whether massage therapy treatments were necessary, your doctor is the person in the best position to determine whether a medical service is necessary for your recovery:

[21] The next threshold lower than the concurrence of two doctors is the opinion of one doctor. In my view the doctor who would be in the best position to provide that opinion would be the attending physician. I therefore find that the test under sub-paragraph (a) for determining if a medical service is “necessary” is that it be deemed to be so in the opinion of the insured’s attending physician. Moreover, considering that the policy contains no parameters stating what the medical service must accomplish, I find that it need only provide some benefit to the insured in the attending physician’s opinion.

[22] It follows then, and I find, that when a medical service has been recommended by the insured’s attending physician, as it has been in this case, it matters not what the insurer’s medical advisor says. The service is “necessary” as that term is used in sub-paragraph 1(a) of Section B of the policy and the insurer is liable to pay for it.

Another common tactic used by insurers is to have the adjuster tell you that certain “medical services,” such as yoga, acupuncture or even gym memberships, are not treatments covered under Section B of the Standard Automobile Policy for New Brunswick. Please, don’t fall for this!

As stated by Chief Justice Drapeau in Axa Insurance Co. v. Rolfe, 2004 NBCA 14, the expression “medical services” found in your Standard Automobile Policy for New Brunswick clearly encompasses therapeutic services prescribed by a physician and provided by a duly qualified health care professional. In short, if your doctor prescribes you medical services provided by qualified health care professionals, then your Section B insurer is required to cover your treatments for as long as your doctor deems necessary, within the policy limits.

Fidelis is with you every step of the way

Don’t let your insurance company take charge of your recovery and take advantage of your vulnerability and lack of legal knowledge. Only lawyers experienced in personal injury claims such as those at Fidelis Law Droit can effectively protect your legal interests and rights. When you choose Fidelis Law Droit, you’re getting an entire team on your side.

Our experienced personal injury lawyers are familiar with all the underhanded tactics frequently used by Section B insurers. You can count on us to uphold your interests diligently, firmly, and decisively. If necessary, your lawyers at Fidelis Law Droit will not hesitate or shy away from taking legal action against your insurer to protect your rights. We’ve seen it all, and we won’t back down.

At Fidelis Law Droit, we’re also here to guide you through the entire claim process, which can be daunting and overwhelming to get through on your own, especially when you’re dealing with an unscrupulous insurance company. Your lawyers at Fidelis Law Droit can help ensure that you get the best treatments available to you. They can also help you get quicker access to treatments and can speed up the claim process.

Remember: your Section B insurer is bound by law to fulfil its obligations and respect your rights. When in doubt, call in the reinforcements without delay! Call Fidelis Law Droit today. We’ll be there with you every step of the way.

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