Statutory Accident Benefits Schedule (SABS) & WSIB Programs of Care

Dennis Polygenis B.Sc. PT., MCPA

Practical Application of the Statutory Accident Benefits Schedule (SABS)

Medical and Rehabilitation Benefits

MVA before June 1, 2016

Minor Injury (MIG) – maximum $3,500 over 12 weeks (OCF-23)

Non-catastrophic – maximum of $50,000 (OCF-18)

Catastrophic – maximum $1,000,000

MVA after June 1, 2016*

Minor Injury (MIG) – maximum $3,500 over 12 weeks (OCF-23)

Non-catastrophic – maximum of $65,000 in combination with attendant care

Catastrophic – maximum of $1,000,000

* Opt-in coverage may be higher

SABS Benefits Summary

Benefit Pre-2016 SABS Post-2016 SABS

Medical and Rehabilitation for non-catastrophic injuries

$50,000

Benefits have been combined and reduced to $65,000 total

Attendant Care for non-catastrophic injuries

$36,000

Medical and Rehabilitation for catastrophic injuries

$1,000,000 Benefits have been combined and

reduced to $1,000,000 total

https://www.fsco.gov.on.ca/en/auto/brochures/pages/brochure_changes10.aspx

SABS Optional Benefits Summary

Pre-2016 SABS Post-2016 SABS

Non-catastrophic injuries

Medical and Rehabilitation for non-catastrophic injuries $100,000

$72,000 and $100,000 options have been eliminated.

New: Combined Medical, Rehabilitation and Attendant Care of $130,000** for non-catastrophic injuries.

Attendant Care for non-catastrophic injuries $72,000

Catastrophic injuries

Not available New: 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 purchased together. ** Duration of benefit is five (5) years for adults.

https://www.fsco.gov.on.ca/en/auto/brochures/pages/brochure_changes10.aspx

Housekeeping & Home Maintenance

MVA before June 1, 2016

Non-catastrophic – maximum of $3,000 per month and $36,000 for up to 2 years after accident

Catastrophic – maximum of $6,000 per month and $1,000,000

MVA after June 1, 2016

Non-catastrophic – maximum of $3,000 per month and $65,000 (including Med/Rehab benefits) for up to 260 weeks

Catastrophic – maximum of $6,000 per month and $1,000,000

Attendant Care Benefits

Prior to June 2016:

Non-catastrophic – $50,000

Catastrophic - $1,000,000

Post June 2016:

Non-catastrophic MIG – 0

Non-catastrophic Outside MIG -$65,000 in

combination with MR benefits

Catastrophic - $1,000,000 in combination with MR

benefits (unless option purchased)

SABS – Duration of Benefits

20. (1) Subject to subsection (2), no medical, rehabilitation and attendant care benefit is payable for expenses incurred,

(a) more than 260 weeks after the accident, in the case of an insured person who was at least 18 years of age at 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 at the 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 of subsection 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) to

maximum of $400 per week (reduced by 70% of post-Accident

earned income).

• Continued payment after 104 weeks is subject to a more

stringent “any occupation” test and payable at a minimum of

$185 per week. Benefits reduce by formula at age 65 (subject

to a 2 year minimum).

Non-Earner Benefits

MVA after September 1, 2010

MVA after June 1, 2016

Payable after 26 weeks at $185 per week if completely unable to carry on a normal life. Increases

to $320 per week from 104 weeks after accident if a student within the 52 weeks prior to the

accident. Benefits reduced by formula at age 65 (subject to 2 year minimum). Payable after age 16

and for life.

Payable after 4 weeks at $185 per week if completely unable to carry on a normal life. Payable after

age 18 and for maximum of 104 weeks.

Caregiver Benefits

Non-Catastrophic – Not Available

Catastrophic – Payable, without waiting period, if substantially unable to

continue caregiving activities, at maximum of $250 per week for first person,

plus $50 for each additional person in need of care. Changes at 104 weeks

to a more stringent “complete inability” test. Terminates once children attain

age 16 or no longer a person in need of care. No adjustment at age 65.

Minor Injury Guideline (MIG)

The MIG - Objectives

The objectives of this Guideline are to:

a) Speed access to rehabilitation for persons who sustain minor injuries in auto accidents

b) Improve utilization of health care resources

c) Provide certainty around cost and payment for insurers and regulated health professionals and

d) Be more inclusive in providing immediate access to treatment without insurer approval for those persons with minor injuries as defined in the SABS and set out in Part 2 of this Guideline.

https://www.fsco.gov.on.ca/en/auto/autobulletins/2014/Documents/a-01-14-1.pdf

The MIG

This Guideline is focused on the application of a functional restoration approach, in addition to the provision of interventions to reduce or manage pain or disability

The SABS and this Guideline are intended to encourage and promote the broadest use of this Guideline, recognizing that most persons injured in car accidents in Ontario sustain minor injuries for which the goods and services provided under this Guideline 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 or interpretation of the SABS and the Guideline.

This Guideline is focused on the application of a functional restoration approach in the management of minor injuries in the acute and sub-acute phases of the injury.

The MIG

3. Impairments that come within this Guideline

Subject to the exception in Section 4 below, an insured person’s impairment comes within this Guideline if the impairment is predominantly a minor injury.

Minor Injury Guideline

Non-minor Injuries

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

Non-minor Injuries

Psychological injuries

Concussion/TBI

TMJ dysfunction

•Intracapsular disc is cartilage not a ligament or tendon

WAD III injuries

•Neurological symptoms

•MRI as a screening device

Identify disc herniations/bulges

•Fractures/dislocations

Non-minor Injuries

Chronic pain •May start as WAD II

•Psychological component

•Pre-existing condition

Minor injury primary factor contributing to the impairment

Arruda and Western Assurance • Arbitrator Jeffrey Shapiro concluded that a diagnosis of chronic pain

syndrome can remove an injured accident victim from the Minor Injury Guideline.

• The insurer did not discharge its “…ongoing duty to assess and reassess a claim as new information is available…” by ignoring the new evidence in this case when presented with it.

The MIG – Pre-Existing Conditions

The existence of any pre-existing condition will not automatically exclude a

person’s impairment from this Guideline. It is intended and expected that

the vast majority of pre-existing conditions will not do so.

Only in extremely limited instances, where compelling evidence provided by

a health practitioner satisfactorily demonstrates that a pre-existing

condition that was documented by a health practitioner before the

accident, and that will prevent a person from achieving maximal recovery

from the minor injury for the reasons described above, is the person’s

impairment to be determined not to come within this Guideline. Exclusion

of a person from this Guideline based on reasons or evidence falling short of

this requirement is inconsistent with the intent of the SABS and this

Guideline.

The MIG – Supplementary Good and Services

8. d) Supplementary goods and services during the treatment phase

Additional funds are available to provide supplementary goods and additional services to support restoration of functioning 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: head set; trolley; braces.

Supportive interventions such as advice/education to deal with accident-related psycho-social issues, such as but not limited 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 the supplementary goods and/or services that are deemed necessary, up to a maximum cost of $400.00, without approval of the insurer.

MIG Math

Funding Category Funding Allowance

Treatment under the MIG Block 1 (Week 1-4) $775

Block 2 (Week 5-8) $500

Block 3 (Week 9-12) $225

Treatment Total $1,500

Other Initial visit $215

Supplementary goods and services $400

Completion of Minor Injury Discharge Report (OCF-24) $85

Other Total $700

Subtotal under the MIG $2,200

Additional funding under s18(1) of SABS

With an OCF-18

$1,300

Total MIG Funding $3,500

Serious impairment

If injury is ‘minor’ the Plaintiff must prove serious impairment to avoid the cap

•An impairment of a physical or cognitive function that results in a substantial inability to perform (the normal activities of the claimant’s daily living)

Catastrophic Injuries

SUMMARY OF NEW CAT DEFINITION (FOR ACCIDENTS AFTER JUNE 2016)

Current System New 2016 SABS Model

Paraplegia/Tetraplegia As outlined by generalized terms in Criterion 1 Relies on definitions as found in the ASIA Impairment Scale

Ambulatory Mobility As outlined by generalized terms in Criterion 2 Relies on more specific definitions of levels of amputation and on the Spinal Cord Independence Measure, Version III

Traumatic Brain Injuries

1. GCS criteria (<9)

2. GOS criteria

3. “Brain impairment” used

1. GCS Criteria discontinued , direct investigation and

imaging criteria introduced

2. Glasgow Outcome Scale Extended (GOS-E)

implemented

3. Language is now “traumatic brain impairment”

55% WPI criteria – Physical

Impairments Utilizes the AMA Guides 4th Edition Unchanged

Combining of Physical and

Mental Health Impairments

Based on case precedent (Desbien, Kuszniers)

in Ontario around the AMA 4th

Required to apply AMA 6th to obtain mental health

QPI and combine with physical findings from AMA

4th

Key tests include BPRS, GAF and PIRS

Mental Health Impairments

Criterion 8 – requires a class 4 or 5 rating as in

Ch. 14 of AMA 4th (Pastore – only in 1

category)

Revised to require 3 or more impairments at Class 4

level, or 1 at a Class 5 level (AMA 4th)

SABS CAT 2016 CHANGES

SABS CAT DEFINITION

2010-2016

GCS

GOS

Psych WPI approaches (Desbien AMA4 Ch. 4,

California GAF)

M/B Criteria 1x Class4

NEW 2016 SABS CAT DEFINITION

ASIA, GOS-E

SCIM, KOSCHI

AMA6: GAF, BPRS, PIRS

‘Bowel Routine’ ‘Radiological Findings’

THE FSCO PERSPECTIVE

FSCO Superintendent’s Report on the Definition of Catastrophic Impairment in the Statutory Accident Benefits Schedule (December 2011):

“I have also reviewed the Expert Panel’s Phase II Report on the qualifications and experience for catastrophic impairment assessors, designed to standardize and maximize the quality of assessments. I have accepted the Panel’s recommendations in this area, with some modifications.”

Superintendent’s Recommendation (5.3): Evaluators conducting assessments of catastrophic impairments must have formal training in the use of the measurement tools that are directly relevant to their scope of practice.

The Panel recommends that all Evaluators involved in the assessment of catastrophic impairment have formal training in the use of the measurement tools that are directly relevant to their scope of practice. The measurement tools are: ASIA Scale; GOS-E; Spinal Cord Independence Measure; GAF; and the AMA Guides.

The Panel believes that proper training would improve the quality of assessments and standardize the way assessments are conducted. As a result, the system would be less prone to assessor bias and inconsistent use of measurement tools.

I accept the Expert Panel’s recommendation.

Superintendent’s Recommendation (5.4):

While I believe the university-based training advocated by the Panel would be an asset, I am not recommending this as a requirement to qualify as an Evaluator. I do however recommend that Evaluators who frequently conduct catastrophic impairment assessments should obtain this further education and thereby strengthen their knowledge and skills.

Superintendent’s Recommendation (5.6):

…. Phase II – One year after the new definition takes effect, all Evaluators must have completed training in the use of measurement tools described in the SABS definition of catastrophic impairment that are relevant to their scope of practice.

SABS FORMS

Application for Accident Benefits (OCF-1)

Completed by claimant when applying for any benefits under the SABS

Basic accident details

Dependents

Employment status

Must be returned in 30 days

Employer’s Confirmation of Income (OCF-2)

Completed by employer when claimant is applying for Income Replacement Benefits (IRB)

Includes hours of work, salary and basic job description

This information is used when scheduling JSA’s

Disability Certificate (OCF-3)

Completed by one of the claimant’s healthcare professionals (chiropractor, dentist, occupational therapist, nurse practitioner, optometrist, physician, physiotherapist, occupational therapist, speech language pathologist or psychologist).

Accident related impairments (ICD-10 CODES)

Pre-accident history

Ability to return to work

Ability to perform housekeeping and home maintenance functions

Caregiver

Attendant Care

Non-earner

***This document is used by adjusters to determine insurer assessments and applicable benefits under the SABS.***

Permission to Disclose Health Information (OCF-5)

Consent from the claimant for the insurer to collect health information from the health practitioner.

Treatment & Assessment Plan (OCF-18)

Application for treatment and assessment services outside of the Minor Injury Guideline.

Application for treatment and assessment services when the goods and services provided under the MIG are utilized.

Must be submitted via HCAI

Fees should follow Professional Services Guidelines (SABS)

Treatment Confirmation Form (OCF-23) MIG

Application for Determination of Catastrophic Impairment (OCF-19)

Form 1: Assessment of Attendant Care Needs

• Normally completed by an occupational therapist or nurse

Level 1: Routine personal care

Level 2: basic supervisory functions

Level 3: complex health/care and hygiene functions

WSIB TREATMENT PATHWAYS

WSIB Programs of Care (POC)

Currently there are 4 programs of care

Musculoskeletal

Shoulder

Low back

Mild Traumatic Brain Injury (MTBI)

Musculoskeletal POC

8 weeks in duration – minimum 6 visits

$500 – if worker able to RTW

$600 – if worker unable to RTW

An allowed WSIB claim, within 8 weeks from the date of injury or recurrence

No clinical evidence of red flags and no evidence of orange or yellow flags that are a barrier to participation in this active rehabilitation program

A diagnosis of one injury or more to a muscle, tendon, ligament, fascia, intra-articular structure or any combination of these structures, causing mild to moderate tissue damage (Grade I or II)

MSK POC Exclusions

tears and ruptures (Grade III) that may require surgical repair

Fractures

Any condition that would preclude a worker from participating in an active rehabilitation program.

Shoulder POC

8 weeks in duration – minimum 7 visits

$560

An allowed shoulder claim by the WSIB within 16 weeks from date of injury

No clinical evidence of significant red or yellow flags

A diagnosis of bursitis, bruises/contusions, impingement syndrome, rotator cuff tendinitis, sprains/strains or partial tear(s) of the rotator cuff or other structures.

Shoulder POC Exclusions

Adhesive Capsulitis (Frozen Shoulder)

Brachial Plexus Injuries

Complete Rotator Cuff Tears

Dislocations

Fractures.

Low Back POC

8 weeks – Two Phases

$770 if completes all phases

With an acute low back injury (up to 6 weeks from date of injury/recurrence)

Who may also have another injury that does not preclude the worker from participating in this Program of Care

Assessed within the first 42 days from date of injury and/or recurrence

With no clinical evidence of significant red or yellow flags

Still at work (regular or modified) or off work

Not hospitalized.

MTBI POC

2 Treatment Blocks

Block 1 – Education Stream (Week 1-2) - $200 (min. 2 visits)

Block 2 – Active Treatment

Cognitive Rehab (up to 24 weeks) - $330 (minimum 6 visits)

Manual Mobilization (up to 24 weeks) - $240 (minimum 5 visits)

Diagnosed with a workplace MTBI by a physician

Approved claim for MTBI with the WSIB

Within one year post date of injury

Not hospitalized.

MTBI Exclusions

moderate or severe brain injury

other injuries being treated through the WSIB Serious Injury Program

cancer of the central nervous system

structural defect of cranial vault at the time of injury

penetrating brain injury

a psychiatric disorder/psychopathology such that the MTBI POC would interfere with the treatment of this condition

physical impairments or concurrent injuries that would prevent the worker from being assessed and/or treated in the MTBI POC.