(2) The
fees and disbursements or maximum fees and disbursements prescribed under
subsection (1) must be published in The Alberta Gazette.
AR 121/2004 s3
5 For
the purpose of ensuring that this Regulation is reviewed for ongoing relevancy
and necessity, with the option that it may be repassed in its present or an
amended form following a review, this Regulation expires on September 30, 2011.
AR 121/2004 s3
Schedule “A”
Section B - Accident Benefits
The Insurer agrees to
pay with respect to each insured person as defined in this section who sustains
bodily injury or death directly and independently of all other causes by an
accident arising out of the use or operation of an automobile.
Subsection 1 ‑
Medical Payments
(1) In respect of
(a) injuries
to which the Diagnostic and Treatment Protocols Regulation applies and
that are diagnosed and treated in accordance with the protocols under that
Regulation, the expenses payable for any service, diagnostic imaging,
laboratory testing, specialized testing, supply, treatment, visit, therapy,
assessment or making a report, or any other activity or function authorized
under that Regulation, and payment must be made in the manner and subject to
the provisions of that Regulation, notwithstanding anything to the contrary in
Section B, and
(b) injuries
(i) to which the Diagnostic and Treatment Protocols Regulation
applies but that are not diagnosed and treated in accordance with the protocols
under that Regulation,
(ii) to which the Diagnostic and Treatment Protocols Regulation ceases
to apply but for which the insured person wishes to make a claim under
provision (3) of “Special Provisions, Definitions, and Exclusions of Section
B”, and
(iii) to which Section B applies, other than those injuries referred to
in subclauses (i) and (ii),
all reasonable expenses
incurred within 2 years from the date of the accident as a result of those
injuries for necessary medical, surgical, chiropractic, dental, hospital,
psychological, physical therapy, occupational therapy, massage therapy,
acupuncture, professional nursing and ambulance services and, in addition, for
other services and supplies that are, in the opinion of the insured person’s
attending physician and in the opinion of the Insurer’s medical advisor,
essential for the treatment or rehabilitation of the injured person,
to the limit of
$50 000 per person.
(2) Notwithstanding provision (1),
(a) expenses
payable in respect of chiropractic services provided under provision (1)(b) are
limited to $750 per person;
(b) expenses
payable in respect of massage therapy services provided under provision (1)(b)
are limited to $250;
(c) expenses
payable in respect of acupuncture services provided under provision (1)(b) are
limited to $250.
(3) Subject to provision (4), the
Insurer is not liable under this provision for those portions of expenses
payable or recoverable under any medical, surgical, dental or hospitalization
plan or law or, except for similar insurance provided under another automobile
insurance contract, under any other insurance contract or certificate issued to
or for the benefit of any insured person.
(4) Except for those portions of
expenses payable or recoverable under any law, provision (3) does not apply to
expenses payable or recoverable for an injury to which the Diagnostic and
Treatment Protocols Regulation applies.
Subsection 2 - Death,
Grief Counselling,
Funeral and Total Disability
Part 1 - Death, Grief Counselling and
Funeral Benefits
Subject to the
provisions of this Part 1, for death, a payment of a principal sum ‑
based on the age and status at the date of the accident of the deceased in a
household where the head of the household or the spouse/adult interdependent partner
or dependants survive ‑ of the following amount:
Age of Deceased at
Date of Accident
|
Status of Deceased at
Date of Accident
|
|
Head of Household
|
Spouse/Adult Interdependent
Partner
|
Dependent Relative
|
Up to age of 4 years
|
‑
|
‑
|
$1000
|
5 to 9 years
|
‑
|
‑
|
2000
|
10 to 17 years
|
$10 000
|
$10 000
|
3000
|
18 to 64 years
|
10 000
|
10 000
|
2000
|
65 to 69 years
|
10 000
|
10 000
|
2000
|
70 years and over
|
10 000
|
10 000
|
1000
|
In addition, funeral
service expenses up to the amount of $5000 in respect of the death of any one
person.
In addition, grief
counselling expenses up to the amount of $400 per family in respect of the
death of any one person.
In addition, with
respect to the death of the head of household,
(a) where
there are 2 or more survivors who are
(i) a spouse/adult interdependent partner and one or more dependent
relatives, or
(ii) 2 or more dependent relatives,
the principal sum payable
is increased 20% for each survivor other than the first, and
(b) where
there is a spouse/adult interdependent partner or dependent relative survivor
living in the household, the death benefit is increased
(i) by $15 000 for the first spouse/adult interdependent partner
or dependent relative survivor, and
(ii) by a subsequent $4000 for each of the remaining survivors.
For the Purposes of this
Part 1
(1) “head
of household” means that member of a household with the largest income in the
year preceding the date of the accident;
(2) “dependent
relative” means a person
(a) under
the age of 18 years for whose support the head of household or the spouse/adult
interdependent partner of the head of household (or both of them) is legally
liable and who is dependent upon either or both of them for financial support;
or
(b) 18
years of age or over and residing in the same dwelling premises as the head of
household who, because of mental or physical infirmity, is principally
dependent on the head of household or the spouse/adult interdependent partner
of the head of household (or both the head of household and the spouse/adult interdependent
partner) for financial support;
(2.1) If the head of household has both a
spouse and an adult interdependent partner, a reference to spouse/adult
interdependent partner or surviving spouse/adult interdependent partner means
(a) the
spouse or surviving spouse, or
(b) the
adult interdependent partner or surviving adult interdependent partner
living in the same
dwelling premises as the head of household.
(3) the
total sum payable shall be paid with respect to death of head of household or
spouse/adult interdependent partner to the surviving spouse/adult
interdependent partner. If there is no
surviving spouse/adult interdependent partner in the household, no amount shall
be payable unless there are surviving dependent relatives, and in that event
the total sum payable shall be divided equally among the surviving dependent
relatives.
(4) The
total amount payable with respect to death due to a common disaster of head of
household and spouse/adult interdependent partner shall be paid equally to surviving
dependent relatives.
(5) The
sum payable with respect to the death of a dependent relative shall be paid to
the head of household or, if he does not survive, to the surviving spouse/adult
interdependent partner of the head of household but, if neither the head of
household nor the spouse/adult interdependent partner survives, no amount is
payable.
(6) amounts
payable under this Part I shall be paid only to a person who is alive 60 days
after the death of the insured person.
(7) the
amount payable under this Part I for the death of any person shall be reduced
by the amount of any payments made to or for such person with respect to the
same accident under Part II, Total Disability.
(8) The amount payable under this Part
for grief counselling is payable to the spouse/adult interdependent partner or
other immediate family member of the deceased in respect of grief counselling
for the immediate family members of an insured person who dies as a result of
the accident.
Part II - Total
Disability
A weekly benefit for
the period during which the injury shall wholly and continuously disable such
insured person, provided
(a) such
person was employed at the date of the accident;
(b) within
60 days from the date of the accident such injury prevents him from performing
any and every duty pertaining to his occupation or employment;
(c) no
benefit shall be payable for the first seven days of such disability or for any
period in excess of 104 weeks.
Amount of Weekly Benefit
-
The weekly benefit
payable shall be the lesser of:
(a) $400
per week, and
(b) 80%
of the average gross weekly earnings, less any payments for loss of income from
occupation or employment received by or available to such insured person under
Subsection 2(A) of this Section B.
The above benefits
shall be subject to the terms of provision (3) below.
For the purpose of
this Part II,
(1) an insured person who is 18 years of
age or over and who is not engaged in an occupation or employment for wages or
profit and is completely incapacitated and unable to perform any of his or her
household duties shall, while so incapacitated, receive $135 per week for not
more than 26 weeks;
(1.1) average gross weekly earnings is the
greater of
(a) average
gross weekly earnings from an occupation or employment for the 4 weeks
preceding the accident, and
(b) average
gross weekly earnings from an occupation or employment for the 52 weeks
preceding the accident;
(2) a
person shall be deemed to be employed
(a) if
actively engaged in occupation or employment for wages or profit at the date of
the accident, or
(b) if
18 years of age or over, so engaged for any six months during the 12 months
preceding the date of the accident.
(3) if the benefits for loss of time
payable under this Part, together with benefits for loss of time under another
contract, including a contract of group accident insurance and a life insurance
contract providing disability insurance, exceed the average gross weekly
earnings of the insured person, the weekly benefit shall be calculated in
accordance with the following formula:
WB = 80%
of WE x PB
PB + OB
where
WB is
the weekly benefit,
WE is
the average gross weekly earnings of the insured person,
PB is
the lesser of $300 and 80% of WE,
OB is
the total of all other weekly benefits payable to the insured person under
other contracts, including a contract of group accident insurance and a life
insurance contract providing disability insurance, excluding benefits under the
Employment Insurance Act (Canada) and the Canada Pension Plan (Canada);
(4) the
disability of the insured person shall be certified by a duly qualified medical
practitioner, if so required by the Insurer.
Subsection 2(A) ‑
Supplemented Benefits
Respecting Accidents Occurring Outside
Alberta in a No‑fault Jurisdiction
(1) In this Subsection,
(a) “accident”
means an event resulting in bodily injury caused by an automobile or by the use
of an automobile or by the load of an automobile, including damage caused by a
trailer;
(b) “applicable
laws” means, with respect to a no‑fault jurisdiction, the laws in force
from time to time governing the system of no‑fault automobile insurance
in that jurisdiction;
(c) “insured
person” means an individual who is a resident of Alberta and who
(i) is an occupant of the described automobile or of a newly acquired
or temporary substitute automobile as defined in this policy,
(ii) is an occupant of an automobile and is
(A) the named insured, or a spouse/adult
interdependent partner of the named insured living in the same dwelling
premises as the named insured, or
(B) a dependent relative of an individual
referred to in paragraph (A) living in the same dwelling premises as the named
insured,
(iii) while a pedestrian, is struck by the described automobile or a
newly acquired or temporary substitute automobile as defined in this policy,
(iv) while a pedestrian, is struck by an automobile and is
(A) the named insured, or a spouse/adult
interdependent partner of the named insured living in the same dwelling
premises as the named insured, or
(B) a dependent relative of an individual
referred to in paragraph (A) living in the same dwelling premises as the named
insured,
(v) is the occupant of an automobile or a pedestrian struck by an
automobile and is
(A) an employee or partner of the named insured
who is provided with the regular use of the described automobile, or a
spouse/adult interdependent partner of the employee living in the same dwelling
premises as the employee or a spouse/adult interdependent partner of the
partner living in the same dwelling premises as the partner, or
(B) a dependent relative of an individual
referred to in paragraph (A) living in the same dwelling premises as that
individual,
or
(vi) is
(A) the occupant of an automobile, or
(B) a pedestrian struck by an automobile
driven by an
individual described in any of subclauses (i) through (v),
but does not include an
individual who is, at the time of an accident in Quebec, the owner or occupant
of an automobile registered in Quebec;
(d) “no‑fault
jurisdiction” means the Province of Quebec, Ontario, Manitoba or Saskatchewan;
(e) “pedestrian”
means an individual who is not an occupant of an automobile;
(f) “resident
of Alberta” means an individual who
(i) is authorized by law to be or to remain in Canada and is living
and ordinarily present in Alberta, and
(ii) meets the criteria for non‑residency in the no‑fault
jurisdiction established by the applicable laws of the no‑fault
jurisdiction.
(2) The
definition of “insured person” under the heading Special Provisions,
Definitions, and Exclusions of Section B does not apply to this Subsection.
(3) Where
an insured person suffers personal injury as a result of an accident occurring
in a no‑fault jurisdiction, the insurer agrees to pay to the insured
person the amount that would be payable under the applicable laws of the no‑fault
jurisdiction as if the insured person were a resident of the no‑fault
jurisdiction.
(4) For
the purposes of calculating an amount payable under (3) in respect of an
accident occurring in Quebec, references in the Automobile Insurance Act
(Quebec) to other statutes or regulations of Quebec used to calculate an amount
payable under (3) shall be read as references to corresponding Alberta statutes
or regulations or federal statutes or regulations that apply in Alberta.
(5) In
any claim or action in Alberta arising out of an accident in Alberta, the
insurer agrees not to exercise its right of subrogation against a resident of
Manitoba or Saskatchewan in respect of Section B - Accident Benefits paid to a
resident of Alberta under an automobile insurance policy issued in Alberta.
(6) No
exclusion or limitation in Section B or in the General Provisions, Definitions
and Exclusions and the Statutory Conditions of this policy may be raised by the
insurer in respect of a claim by an insured person under (3).
Special Provisions,
Definitions,
and Exclusions of Section B
(1) “Insured
person” Defined - In this section, the words “insured person” mean
(a) any
person while an occupant of the described automobile or of a newly acquired or
temporary substitute automobile as defined in this policy;
(b) the
insured and, if residing in the same dwelling premises as the insured, his or
her spouse/adult interdependent partner and any dependent relative of either
while an occupant of any other automobile; provided that
(i) the insured is an individual or are two spouses/adult
interdependent partners in a household;
(ii) such person is not engaged in the business of selling, repairing,
maintaining, servicing, storing, or parking automobiles at the time of the
accident;
(iii) such other automobile is not owned or regularly or frequently
used by the insured or by any person or persons residing in the same dwelling premises
as the insured;
(iv) such other automobile is not owned, hired, or leased by an
employer of the insured or by an employer of any person or persons residing in
the same dwelling premises as the insured;
(v) such other automobile is not used for carrying passengers for
compensation or hire or for commercial delivery;
(c) in
subsection 1 and 2 of Section B only, any person, not the occupant of an
automobile or of railway rolling-stock that runs on rails, who is struck in
Canada, by the described automobile or a newly acquired or temporary substitute
automobile as defined in the policy.
(d) in
subsection 1 and 2 of Section B only, the named insured, if an individual and
his or her spouse/adult interdependent partner and any dependent relative
residing in the same dwelling premises as the named insured, not the occupant
of an automobile or of railway rolling-stock that runs on rails, who is struck
by any other automobile; provided that
(i) such person is not engaged in the business of selling, repairing,
maintaining, servicing, storing, or parking automobiles at the time of the
accident;
(ii) that automobile is not owned or regularly or frequently used by
the insured or by any person or persons residing in the same dwelling premises
as the named insured;
(iii) that automobile is not owned, hired, or leased by an employer of
the insured or by an employer of any person or persons residing in the same
dwelling premises as the named insured;
(e) if
the insured is a corporation, unincorporated association, or partnership, or a
sole proprietorship, any employee or partner of the insured for whose regular
use the automobile is furnished, and his or her spouse/adult interdependent
partner and any dependent relative of either, residing in the same dwelling premises
as such employee or partner, while an occupant of any other automobile; and
(f) in
subsections 1 and 2 of Section B only, any employee or partner of the insured,
for whose regular use the automobile is furnished, and his or her spouse/adult
interdependent partner and any dependent relative of either, residing in the
same dwelling premises as such employee or partner, while not the occupant of
an automobile or of railway rolling-stock that runs on rails, who is struck by
any other automobile; provided that in respect of (e) and (f) above,
(i) neither such employee nor partner of his or her spouse/adult
interdependent partner is the owner of an automobile;
(ii) such person is not engaged in the business of selling, repairing,
maintaining, servicing, storing, or parking automobiles at the time of the
accident;
(iii) such other automobile is not owned or regularly or frequently
used by the employee or partner, or by any person or persons residing in the
same dwelling premises as such employee or partner;
(iv) such other automobile is not owned, hired, or leased by the
insured or by an employer of any person or persons residing in the same
dwelling premises as such employee or partner of the insured;
in respect of (e) above
only,
(v) such other automobile is not used for carrying passengers for
compensation or hire or for commercial delivery.
(1.1) “Prescribed claim form” Defined ‑
In this section, the words “prescribed claim form” mean a form prescribed by
the Minister under section 803 of the Insurance Act.
(1.2) “Spouse/adult interdependent
partner” Defined ‑ In this section, the words “spouse/adult
interdependent partner” mean the spouse or adult interdependent partner, as the
case may be.
(2) Exclusions
-
(a) The
Insurer shall not be liable under provision (1) of subsection 1, nor under part
II of subsection 2 of this section B for bodily injury to any person
(i) resulting from the suicide of such person or attempt thereat,
whether sane or insane; or
(ii) who is entitled to receive the benefits of any workmen’s
compensation law or plan as a result of the accident; or
(iii) where the person at the time of the accident is engaged in a race
or speed test; or
(iv) caused directly by sickness or disease; or
(v) who is using the automobile for any illicit or prohibited trade
or transportation.
(b) The
Insurer shall not be liable under Part II of Subsection 2 of this Section B for
Bodily injury
(i) sustained by any person who is convicted of an offence under
section 253(b) of The Criminal Code (driving with more than 80 milligrams of
alcohol in 100 millilitres of blood) or under section 253(a) of The Criminal
Code (driving while ability to drive impaired by alcohol or a drug) occurring
at the time of the accident, or
(ii) sustained by any person driving the automobile who is under the
age prescribed by the law of the jurisdiction in which the accident occurs as
being the minimum age at which a licence or permit to drive the automobile may
be issued to him; or
(iii) sustained by any person driving the automobile who is not for the
time being either authorised by law or qualified to drive the automobile.
(3) Notice and Proof of Claim ‑
Subject to the Diagnostic and Treatment Protocols Regulation, the
insured person or the insured person’s agent, or the person otherwise entitled
to make a claim or that person’s agent, shall
(a) deliver
personally,
(b) mail,
(c) fax,
or
(d) send
by e‑mail if both parties have agreed to this method of sending and
receiving notices and other documents,
a properly completed
prescribed claim form, containing at least the information referred to in
provision (3.1), to the chief agency or head office of the Insurer in Alberta
within 30 days of the accident, or if giving notice within 30 days is not
reasonable, as soon as practicable after that.
(3.1) Contents of Claim Form ‑ The
completed prescribed claim form must include
(a) details
of the injury, and
(b) details
of the accident that are within the personal knowledge of the insured person.
(3.2) Responsibility for Expenses Related
to Completion of Claim Form ‑ The Insurer shall pay all expenses incurred
by or on behalf of the insured person in completing the medical report portion
of the prescribed claim form.
(3.3) Total Disability Claim ‑ With
respect to a total disability claim, the insured person shall, if so required
by the Insurer, furnish a certificate from a duly qualified medical
practitioner as to the cause and nature of the accident for which the claim is
made and as to the duration of the disability caused thereby.
(4) Medical Reports ‑ Subject to
provision (4.1), the Insurer has the right and the claimant shall afford to a
duly qualified medical practitioner named by the Insurer an opportunity to
examine the person of the insured’s person when and as often as it reasonably
requires while the claim is pending, and also, in the case of the death of the
insured person, to make an autopsy subject to the law relating to autopsies.
(4.1) Exemption ‑ The Insurer has no
right and the claimant is under no obligation under provision (4) with respect
to
(a) injuries
to which the Diagnostic and Treatment Protocols Regulation applies
during the period and with respect to any service, diagnostic imaging,
laboratory testing, specialized testing, supply, treatment, visit, therapy,
assessment, making a report or other activity or function authorized under that
Regulation;
(b) subject
to provision (4.2), any other injuries for which the following services are
provided:
(i) chiropractic services;
(ii) massage therapy services;
(iii) acupuncture services;
(iv) the following services to the extent of the specified limit:
(A) psychological services, up to $600 per
person;
(B) physical therapy services, up to $600 per
person;
(C) occupational therapy services, up to $600
per person.
(4.2) Non‑application ‑
Provision (4.1)(b) does not apply to those injuries to which the Diagnostic
and Treatment Protocols Regulation ceases to apply.
(5) Release
- Notwithstanding any release provided for under the relevant sections of the Insurance
Act of the Province, the insurer may demand, as a condition precedent to
payment of any amount under Section B of the policy a release in favour of the
insured and the Insurer from liability to the extent of such payment from the
insured person or his personal representative or any other person.
(6) When
Moneys Payable -
(a) Except
for the expenses authorized to be paid in accordance with the Diagnostic and
Treatment Protocols Regulation, all amounts payable under Section B other
than benefits under Part II of Subsection 2 shall be paid by the Insurer within
60 days after it has received a completed prescribed claim form. The initial benefits for loss of time under
Part II of Subsection 2 shall be paid within 30 days after the Insurer has received
the completed prescribed claim form, and payments shall be made thereafter
within each 30‑day period while the Insurer remains liable for payments
if the insured person, whenever required to do so, furnishes, prior to payment,
proof of continuing disability.
(b) No
person shall bring an action to recover the amount of a claim under this
section unless the requirements of provisions (3) and (4) are complied with,
nor until the amount of the loss has been ascertained as provided in this
section.
(c) Every
action or proceeding against the Insurer for the recovery of a claim under this
section shall be commenced within one year from the date on which the cause of
action arose and not afterwards.
See also general
provisions, definitions, exclusions, and statutory conditions of this policy.
(7) and (8) Repealed AR 121/2004 s8.
AR 352/72
Sched.A;233/78;12/81;273/82;409/87;171/88;178/89;
306/91;114/95;4/98;36/98;121/2004;259/2006