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Part II .

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Automobile Accident Diagnostic and Treatment Protocols Regulations

made under subsection 5(3) and

Section 159 of the

Insurance Act

R.S.N.S. 1989, c. 231

O.I.C. 2013-21 (January 22, 2013, effective April 1, 2013), N.S. Reg. 20/2013

Table of Contents

Please note: this table of contents is provided for convenience of reference and does not form part of the regulations.

Click here to go to the text of the regulations .

Citation

Definitions for the Act and regulations

Application of regulations

Scope of health care practitioner’s practice

No independent medical examination

Interpretative bulletins and information circulars

Review of regulations

Prescribed fees

Diagnosis and Treatment Protocol for Strains and Sprains

Protocol established for strains and sprains

Developing diagnosis for strains and sprains

Treatment protocol for strains and sprains

Diagnostic and treatment authorization for strains and sprains

Diagnostic and Treatment Protocol for Whiplash Injuries

Protocol established for whiplash injuries

Developing the diagnosis for whiplash injuries

Diagnostic criteria for whiplash I and whiplash II injuries

Treatment protocol for whiplash I and whiplash II injuries

Diagnostic and treatment authorization for whiplash I and whiplash II injuries

Treatment Plans, Limits and Referrals

Treatment plans

Maximum number of visits authorized for treatment under protocols

Assessment for injury to which regulations do not apply

Referrals to other health care practitioners

Applying to insurer for approval of additional

Section B services or supplies

Referral to injury management consultant

Injury Management Consultants Register

Register maintained by Superintendent

Eligibility requirements for injury management consultants

Ceasing to be an injury management consultant

Claims and Payment of Claims

Definitions for Sections 27 to 36

Priority of Sections 27 to 36

Sending claim to insurer

Decision by insurer

If insurer does not respond to applicant

Denial of liability after approval or deemed approval

Making and paying claims

Sending notices

Multiple claims

Concluding report and final invoice

Citation

1 These regulations may be cited as the Automobile Accident Diagnostic and Treatment

Protocols Regulations .

Definitions for the Act and regulations

(1) In these regulations,

“Act” means the Insurance Act ;

“adjunct therapist” means any of the following:

(

i) a massage therapist,

(ii) an acupuncturist,

(iii) an occupational therapist as defined in the Occupational Therapists

Act;

“chiropractor” means a chiropractor as defined in the Chiropractic Act ;

“evidence-informed practice” means the conscientious, explicit and judicious use

of current best practice in making decisions about the care of a patient, that

integrates individual clinical expertise with the best available external clinical

evidence from systematic research while recognizing patient preference and

individual patient considerations in the determination of treatment;

“health care practitioner” means any of the following who is licensed to practice

their profession in the Province:

(

i) a physician,

(ii) a chiropractor, or

(iii) a physiotherapist;

“history”, means, in respect of patient’s injury, all of the following:

(

i) how the injury occurred,

(ii) the current symptoms the patient is experiencing,

(iii) anything the health care practitioner considers relevant from the

patient’s past, including physical, physiological, emotional, cognitive

and social history,

(iv) how the patient’s physical functions have been affected by the injury;

“IMC register” means the register of injury management consultants maintained

under

Section 24;

“injury management consultant” means a health care practitioner who is entered on

the IMC register in accordance with

Section 25;

“International Classification of Diseases” means the most recent version of the

latest revision of the International Statistical Classification of Diseases and

Related Health Problems , Canada, published by the Canadian Institute of Health

Information based on the International Statistical Classification of Diseases and

Related Health Problems published by the World Health Organization;

“patient” means an insured as defined in

Section 104 of the Act;

“physiotherapist” means a physiotherapist as defined in the Physiotherapy Act ;

“prescribed claim form” means a form approved by the Superintendent for the

purpose of these regulations, and includes forms for assessments, treatment plans

and concluding reports;

“protocols” means the diagnostic and treatment protocols established by these

regulations for a sprain, strain or whiplash injury caused by an accident;

“spine” means the column of bone, known as the vertebral column, that surrounds

and protects the spinal cord, and includes all of the following categorizations of the

column according to the level of the body: cervical spine (neck), thoracic spine

(upper and middle back) and lumbar or lumbosacral spine (lower back);

“sprain” means an injury to one or more tendons, to one or more ligaments, or to

both tendons and ligaments;

“Section B benefits” means the benefits required under

Section 140 of the Act as

set out in

Schedule 2 to the Automobile Insurance Contract Mandatory Conditions

Regulations made under the Act;

“strain” means an injury to one or more muscles;

“treatment plan” means a treatment plan described in

Section 18;

“whiplash-associated disorder injury” means a whiplash-associated disorder other

than one that exhibits one or all of the following:

(

i) neurological signs that are objective, demonstrable, definable and

clinically relevant,

(ii) a fracture to the spine or dislocation of the spine;

“whiplash injury” means a whiplash-associated disorder injury;

(2) For the purpose of clause 159(1)(ka) of the Act and these regulations, “assessment”

includes diagnosis.

Application of regulations

(1) These regulations apply to the examination, assessment and treatment or

rehabilitation of strains, sprains and whiplash injuries suffered by an insured as a

result of an accident in respect of which

Section B benefits are payable.

(2) These regulations apply only if

(

a) a patient wishes to be diagnosed and treated in accordance with the

protocols; and

(

b) a health care practitioner chooses to diagnose and treat the patient’s sprain,

strain or whiplash injury in accordance with the protocols.

(3) Except as provided in subsection (4) or as necessary to process a claim under

Sections 28 to 36 for treatment already provided, these regulations do not apply to

an injury, and no treatment is authorized under these regulations, if 90 days have

passed from the date of the accident in which the patient was injured.

(4) If a health care practitioner refers a patient to an injury management consultant

under

Section 23 within 90 days from the date of the accident, any examinations,

further assessment, multi-disciplinary assessment or reports referred to in that

Section may be completed under these regulations after the 90 days.

Scope of health care practitioner’s practice

4 Nothing in these regulations permits a health care practitioner to do anything that is

outside the scope of their practice as determined by their governing body and legislation.

No independent medical examination

5 An insurer does not have the right to overrule a health care practitioner’s diagnosis under

these regulations and cannot introduce an independent medical examination during

treatment under these regulations.

Interpretative bulletins and information circulars

6 The Superintendent may issue interpretative bulletins and information circulars about

any matter the Superintendent considers appropriate under these regulations, including

any of the following:

(

a) describing the roles and general expectations of persons affected by or who

have an interest in the implementation, application, administration and

operation of these regulations;

(

b) respecting the implementation, application, administration and operation of

these regulations.

Review of regulations

7 These regulations must be reviewed

(

a) as part of the mandatory 7-year review of automobile insurance provided for

Section 159BA of the Act; or

(

b) sooner or more often than as required by clause (a), at the discretion of the

Superintendent, and the Superintendent must deliver the result of the review

to the Minister.

Prescribed fees

8 (1 ) The Superintendent may prescribe the fees and disbursements or the maximum

fees and disbursements to be paid for any service, activity or function authorized

under these regulations, including any of the following:

(

a) diagnostic imaging;

(

b) laboratory testing;

(

c) specialized testing;

(

d) supplies;

(

e) treatment plans;

(

f) visits;

(

g) therapies;

(

h) assessments;

(

i) reports and other prescribed claim forms.

(2 ) The fees and disbursements or maximum fees and disbursements prescribed under

subsection (1) must be published in the Royal Gazette,

Part I.

Diagnosis and Treatment Protocol for Strains and Sprains

Protocol established for strains and sprains

9 Sections 10 to 12 are established as the protocol for diagnosing and treating strains and

sprains.

Developing diagnosis for strains and sprains

10 (1 ) Using evidence-informed practice and referring to the International Classification

of Diseases, a health care practitioner must use the following process to diagnose a

strain or sprain:

(

a) take a history of the patient;

(

b) examine the patient;

(

c) make any ancillary investigation considered necessary;

(

d) identify

(

i) for strains, the muscle or muscle groups injured, and

(ii) for sprains, the tendons or ligaments, or both, that are involved and

the specific anatomical site of the injury.

(2) A health care practitioner must use the diagnostic criteria set out in the following

table to determine the degree of severity of a strain (as extracted from Orthopaedic

Physical Assessment by David J. Magee, (5th), (2008), at page 29, and reproduced

with permission from the publisher Elsevier Inc.):

1st Degree

Strain

2nd Degree

Strain

3rd Degree

Strain

Definition of the

degree of strain

few fibres of

muscles torn

about half of

muscle fibres torn

all muscle fibres

torn (rupture)

Mechanism of

injury

overstretch

overload

overstretch

overload

crushing

overstretch

overload

Onset

acute

acute

acute

Weakness

minor

moderate to major

(reflex inhibition)

moderate to major

Disability

minor

moderate

major

Muscle spasm

minor

moderate to major

moderate

Swelling

minor

moderate to major

moderate to major

Loss of function

minor

moderate to major

major (reflex

inhibition)

Pain on isometric

contraction

minor

moderate to major

no to minor

Pain on stretch

yes

yes

not if it is the only

tissued injured;

however, often

with 3rd degree

injuries other

structures will

suffer 1st or 2nd

degree injuries

and be painful

Joint play

normal

normal

normal

Palpable defect

yes (if early)

Crepitus

Range of motion

decreased

decreased

may increase or

decrease

depending on

swelling

(3) A health care practitioner must use diagnostic criteria set out in the following table

to determine the degree of severity of a sprain (as extracted from Orthopaedic

Physical Assessment by David J. Magee, (5th), (2008), at page 29, reproduced with

permission from the publisher Elsevier Inc.):

1st Degree

Sprain

2nd Degree

Sprain

3rd Degree

Sprain

Definition of the

degree of sprain

few fibres of

ligament torn

about half of

ligament torn

all fibres of

ligament torn

Mechanism of

injury

overload

overstretch

overload

overstretch

overload

overstretch

Onset

acute

acute

acute

Weakness

minor

minor to

moderate

minor to

moderate

Disability

minor

moderate

moderate to

major

Muscle spasm

minor

minor

minor

Swelling

minor

moderate

moderate to

major

Pain on isometric

contraction

Pain on stretch

yes

yes

not if it is the

only tissued

injured;

however, often

with 3rd degree

injuries other

structures will

suffer 1st or 2nd

degree injuries

and be painful

Joint play

normal

normal

normal to

excessive

Palpable defect

yes (if early)

Crepitus

Range of motion

decreased

decreased

may increase or

decrease

depending on

swelling.

dislocation or

subluxation

possible

Treatment protocol for strains and sprains

(1) During treatment under these regulations, a health care practitioner must treat a

strain or a sprain by doing all of the following:

(

a) educating the patient about the following matters:

(

i) the desirability of an early return to 1 or more of the following, as

they apply to the patient:

(

A) their employment, occupation or profession,

(

B) their training or education in a program or course,

(

C) their usual daily activities,

(ii) an estimate of the probable length of time that symptoms will last,

the estimated time for recovery and the length of the treatment

process;

(

b) managing inflammation and pain

(

i) by the protected use of ice,

(ii) by elevating the injured area,

(iii) by compression, and

(iv) for a sprain, by using reasonable and necessary equipment to protect

the sprained joint during the acute phase of recovery;

(

c) teaching the patient about maintaining flexibility, balance, strength and the

functions of the injured area;

(

d) giving advice about self-care;

(

e) preparing patient for a return to the following, as they apply to the patient:

(

i) their employment, occupation or profession,

(ii) their training or education in a program or course,

(iii) their usual daily activities;

(

f) discussing the disadvantage of depending on health care providers and

passive modalities of care for extended periods of time;

(

g) prescribing medication, if appropriate, including analgesics for the sole

purpose of short-term treatment of the injury, such as non- opoid [opioid]

analgesics, non-steroidal anti-inflammatory drugs or muscle relaxants, but

treatment under these regulations does not include prescribing narcotics;

(

h) subject to subsection (3), providing treatment that is appropriate and that the

health care practitioner considers necessary to treat or rehabilitate the injury;

(

i) referring the patient for any adjunct therapy that

(

i) the health care practitioner considers necessary to treat or rehabilitate

the injury, and

(ii) is linked to the continued clinical improvement of the patient.

(2) During treatment under these regulations for a 3rd degree strain or sprain, in

addition to the treatment under subsection (1), definitive care of specific muscles,

muscle groups, tendons or ligaments at specific anatomical sites, should be

completed, including all of the following, as required:

(

a) immobilization;

(

b) strengthening exercises;

(

c) surgery;

(

d) if surgery is required, post-operative rehabilitation therapy.

(3) During treatment under these regulations, a health care practitioner must not treat a

1st or 2nd degree sprain or strain to a peripheral joint by a brief, fast thrust to move

the joints beyond the normal range in the anatomical range of motion.

Diagnostic and treatment authorization for strains and sprains

12 (1 ) A health care practitioner is authorized to provide or approve any of the following

in treating a 1st degree, 2nd degree or 3rd degree strain or sprain in accordance

with

Section 11:

(

a) necessary diagnostic imaging, laboratory testing and specialized testing;

(

b) necessary medication, as determined by the health care practitioner, except

that narcotics are not authorized for reimbursement under these regulations;

(

c) necessary supplies, in accordance with any guidelines that may be published

by the Superintendent, to assist in the treatment or rehabilitation of the

injury.

(2) The maximum number of treatment visits authorized under these regulations for

treatment of strains and sprains is as set out in

Section 19.

Diagnostic and Treatment Protocol for Whiplash Injuries

Protocol established for whiplash injuries

13 Sections 14 to 17 are established as the protocol for diagnosing and treating whiplash I

and II injuries.

Developing the diagnosis for whiplash injuries

14 Using evidence-informed practice, a health care practitioner must use the following

process to diagnose a whiplash injury:

(

a) take a history of the patient;

(

b) examine the patient;

(

c) make any ancillary investigation considered necessary;

(

d) identify the anatomical sites.

Diagnostic criteria for whiplash I and whiplash II injuries

(1) A health care practitioner must use all of the following criteria to diagnose a

whiplash I injury:

(

a) complaints of spinal pain, stiffness or tenderness;

(

b) no demonstrable, definable and clinically relevant physical signs of injury;

(

c) no objective, demonstrable, definable and clinically relevant neurological

signs of injury;

(

d) no fractures to or dislocation of the spine.

(2 ) A health care practitioner must use all of the following criteria to diagnose a

whiplash II injury:

(

a) complaints of spinal pain, stiffness or tenderness;

(

b) demonstrable, definable and clinically relevant physical signs of injury

including

(

i) musculoskeletal signs of decreased range of motion of the spine, and

(ii) point tenderness of spinal structures affected by the injury;

(

c) no objective, demonstrable, definable and clinically relevant neurological

signs of injury;

(

d) no fracture to or dislocation of the spine.

(3) An investigation to determine a whiplash II injury and to rule out a more severe

injury may include any of the following:

(

a) for cervical spine injuries, radiographic series in accordance with The

Canadian C-Spine Rule for Radiography in Alter and Stable Trauma

Patients , published in The Journal of the American Medical Association ,

October 17, 2001–Volume 286, No. 15;

(

b) for thoracic, lumbar and lumbosacral spine injuries, radiographic series that

are appropriate to the region of the spine that is injured, if the patient has 1

or more of the following characteristics:

(

i) an indication of bone injury,

(ii) an indication of significant degenerative changes or instability,

(iii) an indication of polyarthritis,

(iv) an indication of osteoporosis,

(

v) a history of cancer.

(5 ) The use of magnetic resonance imaging or computerized tomography is authorized

only if 1 of the following conditions is met:

(

a) a diagnosis cannot be determined from 3 plain view films;

(

b) there are objective neurological or clinical findings.

Treatment protocol for whiplash I and whiplash II injuries

16 During treatment under these regulations, a health care practitioner must treat a whiplash

I or whiplash II injury by doing all of the following:

(

a) educating the patient about the following matters:

(

i) the desirability of an early return to the following, as they apply to the

patient:

(

A) their employment, occupation or profession,

(

B) their training or education in a program or course,

(

C) their usual daily activities,

(ii) an estimate of the probable length of time that symptoms will last,

the estimated time for recovery and the length of the treatment

process,

(iii) that there is likely no serious currently detectable underlying cause of

the pain,

(iv) the importance of postural and body mechanics control,

(

v) that the use of a soft collar is not advisable,

(vi) the probable factors responsible for other symptoms the patient may

be experiencing that are temporary in nature and that are not

reflective of tissue damage, including

(

A) disturbance of balance,

(

B) disturbance or loss of hearing,

(

C) limb pain or numbness,

(

D) cognitive dysfunction, and

(

E) jaw pain;

(

b) giving advice about self-care;

(

c) preparing the patient for return to the following, as they apply to the patient:

(

i) their employment, occupation or profession,

(ii) their training or education in a program or course,

(iii) their usual daily activities;

(

d) discussing the disadvantage of depending on health care providers and

passive modalities of care for extended periods of time;

(

e) prescribing medication, if appropriate, including analgesics for the sole

purpose of short-term treatment of spinal injury, such as non- opoid [opioid]

analgesics, non-steroidal anti-inflammatory drugs or muscle relaxants, but

treatment under these regulations does not include prescribing narcotics;

(

f) recommending

(

i) pain management, as required,

(ii) exercise,

(iii) using heat and ice;

(

g) providing treatment that is appropriate and that the health care practitioner

considers necessary to treat or rehabilitate the injury;

(

h) referring the patient for any adjunct therapy that

(

i) the health care practitioner considers necessary to treat or rehabilitate

the injury, and

(ii) is linked to the continued clinical improvement of the patient.

Diagnostic and treatment authorization for whiplash I and whiplash II injuries

17 (1 ) A health care practitioner is authorized to provide or approve any of the following

in treating a whiplash I or whiplash II injury in accordance with

Section 16:

(

a) necessary diagnostic imaging, laboratory testing and specialized testing;

(

b) necessary medication to manage inflammation or pain, or both, except that

narcotics are not authorized for reimbursement under these regulations;

(

c) necessary supplies, as determined by the Superintendent, to assist in treating

or rehabilitating the injury.

(2) The maximum number of treatment visits authorized under the protocol for

diagnosing and treating whiplash I and II injuries is as set out in

Section 19.

Treatment Plans, Limits and Referrals

Treatment plans

(1) A treatment plan describing the treatments that will be provided under the

protocols must be prepared on a prescribed claim form.

(2) An insurer is not required to approve claims or provide payment for more than 1

treatment plan per patient per accident.

(3) A patient’s treatment plan must be completed by the health care practitioner who

intends to provide the majority of treatment or who will be actively co-ordinating

the care and treatment visits of the patient.

(4) A health care practitioner must provide copies of a patient’s treatment plan to all of

the following:

(

a) the patient’s insurer;

(

b) all practitioners providing treatment for the patient;

(

c) the patient.

(5) A health care practitioner who refers a patient to another health care practitioner

for treatment in accordance with

Section 22 must notify the other practitioner

whether they have completed a treatment plan for the patient.

(6) Before treating a patient under the protocols, a health care practitioner must ask the

patient if any other practitioner has been contacted about the patient’s injury and, if

others have been contacted, must

(

a) document any actions taken by the other practitioners; and

(

b) contact the patient’s insurer to ensure no other treatment plan has been

submitted or is anticipated.

Maximum number of visits authorized for treatment under protocols

(1) One visit to a health care practitioner for assessment of the injury or injuries is

authorized for treatment of

(

a) a single injury diagnosed and treated under the protocols; or

(b) 2 or more injuries from a single accident diagnosed and treated under the

protocols.

(2) In addition to the assessment visit under subsection (1), the maximum number of

visits authorized for treatment of an injury under these regulations is as set out in

the following table:

Injury Diagnosed

Total Number of Visits Authorized

1st or 2nd degree strain or

sprain

combined total of 10 visits to a physiotherapist,

chiropractor or adjunct therapist

3rd degree strain or sprain

combined total of 21 visits to a physiotherapist,

chiropractor or adjunct therapist

whiplash I injury

combined total of 10 visits to a physiotherapist,

chiropractor or adjunct therapist

whiplash II injury

combined total of 21 visits to a physiotherapist,

chiropractor or adjunct therapist

(3) Despite the number of visits authorized under subsection (2), for patients with 2 or

more injuries from a single accident diagnosed and treated under the protocols, the

following are the total number of visits authorized for treatment of the injuries

under these regulations in addition to the assessment visit under subsection (1):

Multiple

Injuries Diagnosed

Total Number of Visits Authorized

2 or more of:

• 1st degree strain

• 2nd degree strain

• 1st degree sprain

• 2nd degree sprain

• whiplash I injury

combined total of 10 visits to a

physiotherapist, chiropractor or adjunct

therapist

1 or more of the injuries in row

A plus 1 or more of:

• 3rd degree strain

• 3rd degree sprain

• whiplash II injury

combined total of 21 visits to a

physiotherapist, chiropractor or adjunct

therapist

2 or more of:

• 3rd degree sprain

• 3rd degree strain

• whiplash II injury

combined total of 21 visits to a

physiotherapist, chiropractor or adjunct

therapist

Assessment for injury to which regulations do not apply

20 Despite

Section 3, if after an assessment a physiotherapist or a chiropractor diagnoses an

injury as one to which these regulations do not apply, the assessment may be claimed

under these regulations.

Referrals to other health care practitioners

21 A health care practitioner may refer a patient to another health care practitioner or to an

adjunct therapist in accordance with the protocols, and any visits to the referred health

care practitioner or adjunct therapist are authorized in accordance with the limitations set

out in

Section 19.

Applying to insurer for approval of additional

Section B services or supplies

22 Nothing in these regulations prevents or limits a patient or a health care practitioner from

applying to an insurer for approval of additional treatments by a health care practitioner

or adjunct therapist outside the limits specified by these regulations in accordance with

the Act and the

Section B benefits.

Referral to injury management consultant

(1) A health care practitioner may refer a patient for 1 visit to an injury management

consultant of the health care practitioner’s choice in any of the following

circumstances:

(

a) the health care practitioner is uncertain about an injury to which the

protocols apply or the diagnosis or treatment of the injury;

(

b) the health care practitioner requires another opinion or report because they

believe that the injury is not

(

i) resolving appropriately, or

(ii) resolving within the time expected;

(

c) the health care practitioner believes the patient exhibits limitation of a

physical or cognitive function that results in the patient’s inability to

perform any of the following:

(

i) the essential tasks of their regular employment, occupation or

profession despite reasonable efforts to accommodate their injury and

the patient’s reasonable efforts to use the accommodation to allow

them to continue their employment, occupation or profession,

(ii) the essential tasks of their training or education in a program or

course that they were enrolled in, or had been accepted for enrolment

in at the time of the accident, despite reasonable efforts to

accommodate their injury and the patient’s reasonable efforts to use

the accommodation to allow them to continue their training or

education,

(iii) their usual daily activities;

(

d) the health care practitioner has a difference of opinion about the diagnosis

or treatment of the injury with another health care practitioner that cannot be

resolved.

(2) On a visit referred under subsection (1), an injury management consultant may

complete an assessment and prepare a report that must include 1 of the following:

(

a) advice about the diagnosis or treatment of the patient;

(

b) a recommendation for a multi-disciplinary assessment of the injury, or an

aspect of the injury, and the health care practitioners who should be

included in that assessment.

(3 ) The visit and the costs and expenses related to an assessment and report by an

injury management consultant under subsection (2) may be claimed under these

regulations, and the visit does not count toward the total limits on visits in

Section

(4) Other than the visit, assessment and report described in this Section, no further

visit to or assessment or report by an injury management consultant in respect of

the same injury is authorized under these regulations.

Injury Management Consultants Register

Register maintained by Superintendent

(1) The Superintendent must maintain and administer a register of injury management

consultants.

(2) The Superintendent must ensure that the IMC register is published in a form and

manner that makes the register accessible to the public.

Eligibility requirements for injury management consultants

(1) A health care practitioner is an injury management consultant under these

regulations if the Superintendent is notified by the following body that the person

meets the requirements set out in subsection (2), and the Superintended

[Superintendent] enters the person’s name in the IMC register:

(

a) for a physician, by the College of Physicians and Surgeons of Nova Scotia;

(

b) for a chiropractor, by the Nova Scotia College of Chiropractors;

(

c) for a physiotherapist, by the Nova Scotia College of Physiotherapists.

(2 ) A person is eligible to be an injury management consultant if the person meets any

qualifications established by the Superintendent and approved by the relevant

colleges, including all of the following qualifications:

(

a) they are an active practising member of their profession;

(

b) they are knowledgeable about the biopsychosocial model;

(

c) they are knowledgeable about assessing acute and chronic pain;

(

d) they are experienced in rehabilitation and disability management;

(

e) they use evidence-informed practices in their practice.

Ceasing to be an injury management consultant

26 A person ceases to be an injury management consultant when all of the following

conditions are met:

(

a) the college for the person’s profession notifies the Superintendent that the

person’s name is to be removed from the IMC register;

(

b) the Superintendent removes the person’s name from the IMC register.

Claims and Payment of Claims

Definitions for Sections 27 to 36

27 In this

Section and Sections 28 to 36,

“applicant” means a patient or health care practitioner who sends a completed

prescribed claim form to the insurer in accordance with

Section 29;

“business day” means any day other than a Saturday, Sunday or a holiday as

defined in the

Interpretation Act .

Priority of Sections 27 to 36

28 Sections 27 to 36 prevail in respect of any inconsistency or conflict between these

provisions and the required

Section B benefits.

Sending claim to insurer

(1) A patient or health care practitioner may not make a claim under these regulations

until the patient has completed the applicable prescribed claim form for their

injury.

(2) The completed prescribed claim form under subsection (1) must be sent to the

insurer no later than

(a) 10 business days after the date of the accident; or

(

b) if the deadline in clause (

a) is not reasonable, as soon as practicable.

Decision by insurer

30 (1 ) No later than 5 business days after receiving a completed prescribed claim form, an

insurer must send the applicant a decision notice that

(

a) approves the claim; or

(

b) refuses the claim, including the reasons for refusing the claim.

(2) A claim may be refused by an insurer for the following reasons only:

(

a) the person who was injured does not meet the definition of “patient”;

(

b) the insurer is not liable to pay as a result of an exclusion set out in

Subsection 3 - Special Provisions,

Definitions and Exclusions of this

Section

of the

Section B benefits;

(

c) there is no existing contract that applies to the person who was injured;

(

d) the injury was not caused by an accident arising out the use or operation of

an automobile.

(3) If an insurer indicates to a health care practitioner that no other treatment plans

have been submitted or are anticipated in respect of a patient, the insurer must not

refuse any prescribed claim forms submitted by the health care practitioner in

respect of the treatment plan for that patient.

If insurer does not respond to applicant

31 If an insurer does not send a decision notice back to the applicant in accordance with

Section 30, then the insurer is deemed to have approved the claim.

Denial of liability after approval or deemed approval

(1) An insurer who approves a claim, or is deemed to have approved a claim, may

later refuse the claim by sending a notice in writing to all of the following,

including the reasons why the claim is denied:

(

a) the patient;

(

b) each person that the patient is authorized to visit or is authorized to provide

services or supplies to the patient.

(2 ) An insurer may refuse a claim under subsection (1) for the reasons set out in

subsection 30(2) only.

(3) A notice under this

Section takes effect on the date it is received by the person to

whom it is sent and, on and after the date the patient receives the notice, the insurer

is not liable to pay any future claims under these regulations relating to the

patient’s injuries.

Making and paying claims

33 (1 ) Any treatment that is authorized under these regulations may be the subject of a

claim under subsection (2).

(2) No later than 30 days after receiving it, an insurer must pay any claim for treatment

that is authorized under these regulations and that meets all of the following

conditions:

(

a) it includes all related invoices and, if submitted by a patient, receipts for the

supplies and services claimed together with satisfactory evidence that the

treatment is authorized by these regulations;

(

b) if submitted by a health care practitioner, injury management consultant or

adjunct therapist, it is verified by the patient treated.

Sending notices

34 Any notice required or permitted to be sent under Sections 28 to 36 may be sent by any

of the following methods:

(

a) delivered personally;

(

b) mailed;

(

c) faxed;

(

d) transmitted by e-mail, if both parties agree to this method of sending and

receiving notices.

Multiple claims

35 For greater certainty, a person who has a claim under these regulations and a claim for

other benefits as set out in Subsection 3 - Special Provisions,

Definitions and Exclusions

of this

Section of the

Section B benefits, must comply with these regulations and the

Section B benefits, according to the claim or claims made.

Concluding report and final invoice

(1) The health care practitioner who completed the majority of treatments for a patient

must prepare a concluding report on a prescribed claim form and send it to the

insurer after treatment under these regulations is completed.

(2) A health care practitioner must send the patient a copy of the final invoice they

sent to the insurer, together with a standard letter that includes the following

statements:

“We have billed your insurer the amounts shown on the attached invoice for the

goods and services listed. Please check the invoice and report any errors to us and

to your insurer.”

Legislative History

Reference Tables

Automobile Accident Diagnostic and Treatment

Protocols Regulations

N.S. Reg.

20/2013

Insurance Act

Note: The

information in these tables does not form part of the regulations and is

compiled by the Office of the Registrar of Regulations for reference only.

Source Law

The current consolidation of the Automobile Accident Diagnostic and Treatment Protocols Regulations made

under the Insurance Act includes all

of the following regulations:

N.S.

Regulation

In force

date*

How in force

Royal Gazette

Part II Issue

20/2013 1

Apr 1, 2013

date specified

Feb 8, 2013

The following regulations are not

yet in force and are not included in the current consolidation:

N.S.

Regulation

In force

date*

How in force

Royal Gazette

Part II Issue

*See subsection 3(6) of the Regulations Act for

rules about in force dates of regulations.

Amendments by Provision

ad. = added

am. = amended

fc. = fee change

ra. = reassigned

rep. = repealed

rs . = repealed and substituted

Provision affected

How affected

..........................................................

Note that changes to headings are not

included in the above table.

Editorial Notes and

Corrections

Note

Effective

date

First clause

16(

h) in original text relettered as clause 16(

g) for the purposes of this consolidation.

The Occupational Therapists Act referred to in the definition

of “adjunct therapist” is repealed and replaced with the Regulated Health

Profession Act , S.N.S. 2023, c. 15, in accordance with s. 194 of that Act,

effective on proclamation (N.S. Reg. 44/2025).

Mar 31, 2025

Repealed and Superseded

N.S.

Regulation

Title

In force

date

Repealed

date

Note: Only regulations that are specifically repealed and

replaced appear in this table. It may not reflect the entire history of

regulations on this subject matter.