Statutory Accident Benefits Schedule (SABS) & WSIB .

Statutory Accident Benefits Schedule(SABS) & WSIB Programs of CareDennis Polygenis B.Sc. PT., MCPA

Practical Application of the StatutoryAccident Benefits Schedule (SABS)

Medical and Rehabilitation BenefitsMVA before June 1, 2016Minor Injury (MIG) – maximum 3,500 over 12 weeks (OCF-23)Non-catastrophic – maximum of 50,000 (OCF-18)Catastrophic – maximum 1,000,000MVA after June 1, 2016*Minor Injury (MIG) – maximum 3,500 over 12 weeks (OCF-23)Non-catastrophic – maximum of 65,000 in combination with attendantcareCatastrophic – maximum of 1,000,000* Opt-in coverage may be higher

SABS Benefits SummaryBenefitMedical and Rehabilitationfor non-catastrophic injuriesAttendant Care for noncatastrophic injuriesMedical and Rehabilitationfor catastrophic injuriesPre-2016 SABSPost-2016 SABS 50,000Benefits have been combined andreduced to 65,000 total 36,000 res/pages/brochure changes10.aspxBenefits have been combined andreduced to 1,000,000 total

SABS Optional Benefits SummaryPre-2016 SABSPost-2016 SABS Non-catastrophic injuriesMedical and Rehabilitation for non-catastrophicinjuries 100,000 72,000 and 100,000 options have been eliminated. Attendant Care for non-catastrophic injuries 72,000New: Combined Medical, Rehabilitation and Attendant Care of 130,000** for non-catastrophic injuries. Catastrophic injuries Not availableNew: Combined Medical, Rehabilitation and Attendant Care of 1,000,000 for catastrophic injuries only. * 130,000 optional combined (non-catastrophic injuries) and 1 million optional (all injuries) cannot be purchasedtogether.** Duration of benefit is five (5) years for s/pages/brochure changes10.aspx

Housekeeping & Home MaintenanceMVA before June 1, 2016Non-catastrophic – maximum of 3,000 per month and 36,000 for up to2 years after accidentCatastrophic – maximum of 6,000 per month and 1,000,000MVA after June 1, 2016Non-catastrophic – maximum of 3,000 per month and 65,000(including Med/Rehab benefits) for up to 260 weeksCatastrophic – maximum of 6,000 per month and 1,000,000

Attendant Care BenefitsPrior to June 2016: Non-catastrophic – 50,000 Catastrophic - 1,000,000Post June 2016: Non-catastrophic MIG – 0 Non-catastrophic Outside MIG - 65,000 incombination with MR benefits Catastrophic - 1,000,000 in combination with MRbenefits (unless option purchased)

SABS – Duration of Benefits20. (1) Subject to subsection (2), no medical, rehabilitation and attendant care benefit is payable for expensesincurred,(a) more than 260 weeks after the accident, in the case of an insured person who was at least 18 years of ageat the time of the accident; or(b) after the insured person’s 28th birthday, in the case of an insured person who was under 18 years of age atthe time of the accident. O. Reg. 251/15, s. 10.(2) The time limits set out in subsection (1) do not apply in respect of an insured person,(a) who sustains a catastrophic impairment as a result of the accident; or(b) who is entitled to optional medical, rehabilitation and attendant care benefits under paragraph 4 ofsubsection 28 (1) or catastrophic impairments benefits under paragraph 5 of subsection 28 (1). O. Reg.251/15, s. 10.

Income Replacement Benefits After first week, paid at 70% of gross pre-Accident income(reduced by collateral benefits available or received) tomaximum of 400 per week (reduced by 70% of post-Accidentearned income). Continued payment after 104 weeks is subject to a morestringent “any occupation” test and payable at a minimum of 185 per week. Benefits reduce by formula at age 65 (subjectto a 2 year minimum).

Non-Earner BenefitsMVA after September 1, 2010Payable after 26 weeks at 185 per week if completely unable to carry on a normal life. Increasesto 320 per week from 104 weeks after accident if a student within the 52 weeks prior to theaccident. Benefits reduced by formula at age 65 (subject to 2 year minimum). Payable after age 16and for life.MVA after June 1, 2016Payable after 4 weeks at 185 per week if completely unable to carry on a normal life. Payable afterage 18 and for maximum of 104 weeks.

Caregiver BenefitsNon-Catastrophic – Not AvailableCatastrophic – Payable, without waiting period, if substantially unable tocontinue caregiving activities, at maximum of 250 per week for first person,plus 50 for each additional person in need of care. Changes at 104 weeksto a more stringent “complete inability” test. Terminates once children attainage 16 or no longer a person in need of care. No adjustment at age 65.

Minor Injury Guideline (MIG)

The MIG - ObjectivesThe objectives of this Guideline are to:a) Speed access to rehabilitation for persons who sustain minor injuries in autoaccidentsb) Improve utilization of health care resourcesc) Provide certainty around cost and payment for insurers and regulated healthprofessionals andd) Be more inclusive in providing immediate access to treatment without insurerapproval for those persons with minor injuries as defined in the SABS and setout in Part 2 of this ulletins/2014/Documents/a-01-14-1.pdf

The MIGThis Guideline is focused on the application of a functional restoration approach, inaddition to the provision of interventions to reduce or manage pain or disabilityThe SABS and this Guideline are intended to encourage and promote the broadestuse of this Guideline, recognizing that most persons injured in car accidents inOntario sustain minor injuries for which the goods and services provided under thisGuideline are appropriate.Usage of the Guideline by all stakeholders will be monitored on an ongoing basis,with a view to early identification and response to inappropriate application orinterpretation of the SABS and the Guideline.This Guideline is focused on the application of a functional restoration approach inthe management of minor injuries in the acute and sub-acute phases of the injury.

The MIG3. Impairments that come within this GuidelineSubject to the exception in Section 4 below, an insured person’s impairmentcomes within this Guideline if the impairment is predominantly a minorinjury.

Minor Injury Guideline

Non-minor InjuriesAn insured person’s impairment does not come within this Guideline if theinsured person’s impairment is predominantly a minor injury but, based oncompelling evidence provided by his or her health practitioner, the insuredperson has a pre-existing medical condition that was documented by ahealth practitioner before the accident and that will prevent the insuredperson from achieving maximal recovery from the minor injury if he or sheis subject to the 3,500 limit referred to in section 18(1) of the SABS or islimited to the goods and services authorized under this Guideline.

Non-minor InjuriesPsychological injuriesConcussion/TBITMJ dysfunction Intracapsular disc is cartilage not a ligament or tendonWAD III injuries Neurological symptoms MRI as a screening device Identify disc herniations/bulges Fractures/dislocations

Non-minor InjuriesChronic pain May start as WAD II Psychological component Pre-existing condition Minor injury primary factor contributing to theimpairment Arruda and Western Assurance Arbitrator Jeffrey Shapiro concluded that a diagnosis of chronic painsyndrome can remove an injured accident victim from the Minor InjuryGuideline. The insurer did not discharge its “ ongoing duty to assess and reassess aclaim as new information is available ” by ignoring the new evidence inthis case when presented with it.

The MIG – Pre-Existing ConditionsThe existence of any pre-existing condition will not automatically exclude aperson’s impairment from this Guideline. It is intended and expected thatthe vast majority of pre-existing conditions will not do so.Only in extremely limited instances, where compelling evidence provided bya health practitioner satisfactorily demonstrates that a pre-existingcondition that was documented by a health practitioner before theaccident, and that will prevent a person from achieving maximal recoveryfrom the minor injury for the reasons described above, is the person’simpairment to be determined not to come within this Guideline. Exclusionof a person from this Guideline based on reasons or evidence falling short ofthis requirement is inconsistent with the intent of the SABS and thisGuideline.

The MIG – Supplementary Good and Services8. d) Supplementary goods and services during the treatment phaseAdditional funds are available to provide supplementary goods and additional services to support restoration offunctioning and address barriers to recovery. The supplementary goods and services may include but are not limited to:Treatment services for the additional minor injuries arising from the same accident.Goods required for self-directed exercise and/or pain management such as, but not limited to: theraband; gym ball;hot/cold packs; back support; lumbar roll; etc.Assistive devices required to maintain/return to work/school/home or personal activity such as but not limited to: headset; trolley; braces.Supportive interventions such as advice/education to deal with accident-related psycho-social issues, such as but notlimited to: distress; difficulties coping with the effects of his/her injury; driving problem/stress.The health practitioner, a regulated health professional or an appropriate health care provider may provide thesupplementary goods and/or services that are deemed necessary, up to a maximum cost of 400.00, without approval ofthe insurer.

MIG MathTreatment under the MIGOtherAdditional funding under s18(1) ofSABSFunding CategoryFunding AllowanceBlock 1 (Week 1-4) 775Block 2 (Week 5-8) 500Block 3 (Week 9-12) 225Treatment Total 1,500Initial visit 215Supplementary goods and services 400Completion of Minor Injury Discharge Report (OCF-24) 85Other Total 700Subtotal under the MIG 2,200With an OCF-18 1,300Total MIG Funding 3,500

Serious impairmentIf injury is ‘minor’ the Plaintiff must prove serious impairmentto avoid the cap An impairment of a physical or cognitive function thatresults in a substantial inability to perform (the normalactivities of the claimant’s daily living)

Catastrophic Injuries

SUMMARY OF NEW CAT DEFINITION(FOR ACCIDENTS AFTER JUNE 2016)Current SystemParaplegia/TetraplegiaAmbulatory MobilityTraumatic Brain Injuries55% WPI criteria – PhysicalImpairmentsCombining of Physical andMental Health ImpairmentsMental Health ImpairmentsAs outlined by generalized terms in Criterion 1New 2016 SABS ModelRelies on definitions as found in the ASIAImpairment ScaleRelies on more specific definitions of levels ofAs outlined by generalized terms in Criterion 2 amputation and on the Spinal Cord IndependenceMeasure, Version III1.GCS criteria ( 9)2.GOS criteria3.“Brain impairment” usedUtilizes the AMA Guides 4th Edition1.GCS Criteria discontinued , direct investigation andimaging criteria introduced2.Glasgow Outcome Scale Extended (GOS-E)implemented3.Language is now “traumatic brain impairment”Unchanged Required to apply AMA 6th to obtain mental healthQPI and combine with physical findings from AMA4th Key tests include BPRS, GAF and PIRSBased on case precedent (Desbien, Kuszniers)in Ontario around the AMA 4thCriterion 8 – requires a class 4 or 5 rating as inCh. 14 of AMA 4th (Pastore – only in 1category)Revised to require 3 or more impairments at Class 4level, or 1 at a Class 5 level (AMA 4th)

SABS CAT 2016 CHANGESSABS CAT DEFINITION2010-2016GCSNEW 2016 SABS CAT DEFINITIONGOSASIA, GOS-EPsych WPI approaches(Desbien AMA4 Ch. 4,California GAF)SCIM, KOSCHIAMA6: GAF, BPRS, PIRSM/B Criteria 1x Class4‘Bowel Routine’ ‘Radiological Findings’