Employee Benefit Plans and Motor Vehicle Accidents

Few people realize that, generally, when there are injuries resulting from a motor vehicle accident (MVA) requiring treatment by paramedical services, auto insurers are the second payor when an employee benefits plan is in place.  Knowing this and knowing the process involved can ease the stress of claiming after an accident.

Other than medical expenses covered by provincial health plans, reimbursement for those expenses not covered by the province can be quite challenging. The auto insurers often make it as complicated and bureaucratic as possible, causing some to give up and never claim for their treatment at all. Insurance regulations allow for auto insurers to be second payor where an employee benefits plan is in place. As such, insurers require that the benefits be exhausted prior to submitting the remaining amount to them.  In fact, an employer plan could potentially foot the entire bill.

There are exceptions. While all insurance carriers are deemed to be first payor, some exceptions include adjudication-only providers, such as MDM Insurance or Green Shield Canada, who do not fall under the definition of insurers.  Even in these cases, the claims must first be submitted to the benefits provider and officially declined before being submitted to the auto insurer.

In a recent example, an individual involved in a MVA suffered a back strain and soft tissue injury in her arm. The initial trip to the hospital and stiches for a cut were covered by the Ontario Health Insurance Plan (OHIP). She required chiropractic and massage treatments for her other injuries.  Recovering the expenses went as follows:

  • All claims were submitted to her benefits provider. Once maximums were met, they issued declines.
  • The next payor was her spouse’s plan as her benefits were co-ordinated with his. All remaining claims were submitted. Again, once maximums were met, declines were issued.
  • She then submitted the balance to the auto insurer who subsequently requested a full treatment plan, submitted to their medical underwriter for approval, as well as a more details and a financial explanation supporting the benefit carrier’s declines.

Eventually, all MVA related claims were paid.

Much work by the injured party went into recovering the medical expenses. However, this is a process that won’t be changing anytime soon. Our advice is to be meticulous from the beginning.

  • Request a comprehensive treatment plan from the paramedical providers, including cost estimates;
  • submit all claims to your benefits carriers, regardless of whether maximums have been reached, or even to ASO providers, such as MDM who may not be obligated to cover those costs;
  • submit remaining claims to coordinated benefit plans, if available.
  • retain all explanation of benefit reports (EOBs) and unpaid claim amounts (including co-pay amounts) and
  • submit the entire package to the auto insurer, according to their requirements or instructions
  • Most of all, be persistent and don’t give up.

Please contact ASSOCIUM Benefits if you have questions or require assistance with MVA related claims.

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ASSOCIUM Benefits is a very unique employee group benefits provider, focused on supporting benefits advisors and their employer clients. We provide Brokers and Plan Sponsors with a range of solutions from traditional group benefits to more customized, cost and tax effective employee compensation. Let’s connect to find out how we can help.