Medical or rehabilitation benefit under section 38

(1) This section applies to a claim for a medical or rehabilitation benefit under section 38 if the insurer gives the insured person a notice informing the insured person that the insurer will pay the expenses without the submission of a treatment plan under that section. O. Reg. 281/03, s. 17.

(2) If the insurer gives the insured person a notice under subsection (1),

(a) the notice shall describe the expenses that the insurer will pay without the submission of a treatment plan and shall specify,

(i) the types of expenses,

(ii) any restrictions on the amount of the expenses, and

(iii) any restrictions on when the expenses may be incurred;

(b) the insurer shall pay expenses described in the notice within 30 days after receiving an invoice for them; and

(c) if there is a dispute about whether, for the purpose of subsection 14 (2) or 15 (5), an expense described in the notice is reasonable or necessary, the insurer shall pay the expense pending resolution of the dispute in accordance with sections 279 to 283 of the Act. O. Reg. 281/03, s. 17.

(3) The insurer shall give the insured person a notice disclosing any conflict of interest that the insurer has relating to any person who will provide goods or services to whom the insured person is referred by the insurer. O. Reg. 281/03, s. 17; O. Reg. 533/06, s. 8 (1).

(4) Every member of a health profession and social worker who refers an insured person to another person to obtain goods or services in respect of which a medical or rehabilitation benefits will be paid by an insurer under this section shall give the insurer and the insured person written notice disclosing any conflict of interest the member of the health profession or social worker has relating to the provision of the goods or services. O. Reg. 546/05, s. 15; O. Reg. 533/06, s. 8 (2).

(5) If a conflict of interest is disclosed under subsection (4), the insurer may give the insured person a notice requiring the insured person to submit a treatment plan to the insurer under section 38 and, if a notice is given under this subsection,

(a) the insurer is relieved of any obligation under this section to pay expenses other than expenses incurred before the notice was given;

(b) subsections (1) to (4) do not apply; and

(c) the insured person may submit an application and treatment plan under section 38. O. Reg. 281/03, s. 17.