Further Questions for Part VII Benefits
The following paragraphs answer some of the common questions with Part VII coverage.
Does ICBC get credit for part VII benefits paid?
The simple answer to this question is usually “YES”. When ICBC is faced with having to pay an injury claim or a death claim, it is entitled to seek a credit for those amounts, which have already been paid in the form of Part VII benefits to the injured person or to the family.
For example, if an injured person has $5,000 in income loss but ICBC has already paid $1,200 in TTDs, the injured person is only entitled to recover $3,800 in a claim against the driver at fault for the accident.
If ICBC refused to pay part 7 benefits, what can I do?
ICBC can be sued for the payment of Part VII benefits under contract, but the lawsuit must be started within 2 years of the date of the accident or within 2 years of the date of the last Part VII payment, whichever is later. If the only issue is whether a medical or rehab expense is “reasonable”, this question must be decided by arbitration.
In most cases, pursuing a lawsuit or arbitration is simply not worth the time and money necessary to have the case decided. ICBC knows that economic reality and will take positions on Part VII claims that are clearly wrong but the adjuster knows full well the insured has very little recourse to get the right decision.
There is also the option of pursuing the ICBC internal review procedure but usually that approach is not that productive.
Who at ICBC handles my part VII claim?
ICBC has a Rehab Department with offices across the Province, which deal only with Part VII claims. The adjusters in the Rehab Department, who call themselves rehab coordinators, deal only with the Part VII claims and are not concerned with any additional injury or death claims. Generally, only those cases involving serious injuries with anticipated long-term problems are referred to this department.
In most cases, the same adjuster in the ICBC claims center who is dealing with the injury claim deals with the Part VII claim. The problem with this system is that the adjuster who is providing Part VII coverage may feel that providing that coverage will make the injury claim larger or better. Hence, some adjusters tend to deny payment under Part VII so that it will not appear that ICBC has accepted the severity of the injuries. Also, some adjusters at ICBC avoid paying Part VII benefits because the less treatment a person receives, the easier it is to argue the injuries are minor. Similarly, if TTDs are not paid, ICBC may be able to “starve” the injured party back to work.
While there is an obvious conflict in one adjuster handling both the Part VII and the injury claim for the same person, ICBC refuses to acknowledge this conflict. A claimant can request that his or her file be referred to the Rehab Department, but there is no way to ensure that this will be done. Also the Rehab Department only accepts serious injury claims.
Can ICBC insist that I see a doctor of their choice?
The basic answer to this question is “YES”. ICBC is entitled to have a claimant seen by a doctor of its choice to determine if the person is entitled to Part VII benefits. This right is sometime misused by ICBC, as the primary purpose of the assessment is to assist with the injury or death claim, not to determine whether Part VII benefits should be paid. As a result, ICBC will ask claimants to see their doctor of choice earlier and more often than if ICBC was only dealing with an injury claim.
If you refuse to attend the assessment, ICBC can cut off your Part VII benefits. In turn, ICBC can then argue, in your injury claim, that they are owed a credit against your damages for expenses they would have paid under Part VII but did not because of your refusal to attend the assessment.
One questions the fairness of this situation. Realistically, a claimant will have to fight hard to get ICBC to pay anything under Part VII through the claim, but then ICBC will make the argument that they would have paid for everything when it serves its interests. Also, chances are that the ICBC appointed doctor is going to minimize the amount of treatment you need and suggest an early return to work. Otherwise, ICBC probably would not be using that expert for the opinion.
Can the ICBC adjuster insist that I take certain treatments?
Provided that your own doctor thinks the treatment is likely to help you and ICBC offers to pay for the treatment, Section 90 of the Regulations allows ICBC to insist that you undergo this treatment and allows ICBC to cut off benefits if you refuse to undergo this treatment.