Tazmeen Lalani

The insured suffered catastrophic injuries in a motor vehicle accident and was placed in a long-term care facility.

A dispute arose over whether her automobile insurer was required to pay her chronic care accommodation co-payments under the SABS-1994.

The arbitrator ordered the insurer to pay the full co-payments and awarded a $10,000 special award.

On appeal, the Director's Delegate varied the order, finding that while the insurer is responsible for the co-payments, the SABS secondary payer rule requires the insured to apply for reasonably available partial or full exemptions under the Health Insurance Act to reduce the amount payable.

The special award was revoked because the insurer's delay was not unreasonable given the insured's failure to pursue these exemptions.

The Delegate also revoked the arbitrator's award for past attendant care and support worker services that were never actually incurred.

The applicant sustained a severe brain injury in a motor vehicle accident and required long-term care in a nursing home.

She sought payment from her insurer for chronic care co-payments, ongoing and retroactive attendant care, rehabilitation services, and a special award.

The arbitrator held that the insurer was primarily responsible for paying the long-term care accommodation fees under the Statutory Accident Benefits Schedule, subject to deductions for the applicant's low-income subsidy.

The arbitrator awarded ongoing and retroactive funding for a community support worker to reduce the applicant's social isolation, as well as funding for a case manager and specific therapy assessments.

A special award of $10,000 was ordered against the insurer for unreasonably withholding the co-payments and misrepresenting its obligations under the Schedule.