Information about Insurance Programs

Extended Health Insurance

Most individual or employee benefits plans contain some coverage for speech-language pathology services. Every plan is different because every employer negotiates their own plan with the insurer. Some questions to ask when looking into your coverage:

  • Do I need a doctor’s referral? While Sound Expression does not require you to have a doctor’s referral, some insurance plans do.
  • How much coverage do I have and for what period of time? Most plans are based on a calendar year, but some are different.
  • Does the coverage pay for the first $X of services, or is there a limit per session up to an annual maximum? For example, some plans cover the first $1,000 of services provided in the year, while others cover $50 per session up to a maximum of $1,000 per year.
  • Can I use my own coverage to learn how to work with my child or spouse? For example, let’s say each person in the family has $1,000 per year for speech-language pathology services and there is a child coming in for stuttering therapy. A parent participates in the session in order to learn from the speech-language pathologist what to do with the child when working on therapy activities at home. Can the cost for that session therefore be split between the child’s and the parent’s names? Clinically, it makes complete sense because, even though the child is the ultimate beneficiary, the parent is learning from the speech-language pathologist as much as the child is. It would be similar for a couple where one person had a stroke and the other person would like to participate in sessions to learn from the speech-language pathologist. Most, but not all, insurance plans allow this “family training”, so this greatly increases the amount of coverage you have for speech-language pathology services.

If you’ve submitted a claim and your extended health insurer denies it, let us know – we may be able to send a letter to address their reason for denial and get them to reconsider paying the claim.

Auto Insurance

If your injury is related to a car accident, your therapy services should be covered by your car insurance benefits. This system can be overwhelming! But rest assured – we know the rules and how the system works. Let us take some of the stress away – we’ll stay on top of any forms, timelines and other rules related to getting you the speech-language pathology services you need.

Please read here about huge cuts to your auto insurance benefits imposed by the government in 2010 and the significant changes that took effect on June 1, 2016:

Some important things you may want to know:

  • When your speech-language pathologist puts in a request to complete an assessment or provide treatment for you, the insurer must respond within 10 business days or else the treatment is deemed approved until they get around to responding.
  • If your insurer denies the request for assessment or treatment, they are no longer required to get a second opinion from a regulated health professional. They can choose to get a second opinion, although after September 1, 2010, there are no longer regulated timeframes for this to occur, so you could potentially wait for months. The other option is to take your request for assessment or treatment to “mediation” at the Financial Services Commission of Ontario. This is not a simple process, so you will probably need a lawyer to assist you with navigating this system.
  • There is a distinction in the auto insurance regulations between injuries that are “catastrophic” and those that are “non-catastrophic.” The distinction is unfortunately sometimes arbitrary – it is based on some rules and guidelines, but when it comes to cognitive and psychological injuries, it is incredibly difficult to make this distinction with any degree of accuracy. If your injury is considered “non-catastrophic”, your eligibility for therapy has been drastically reduced – instead of a combined limit of $86,000 for medical, rehabilitation and attendant care funding, the limit is dropping to $65,000. If your injury is considered “catastrophic”, the previous $2 million combined limit for medical, rehabilitation and attendant care funding is dropping to $1 million.

Insurance companies should be informing policy holders of these changes, via mail. Drivers can purchase additional coverage for higher premiums. Talk to your insurance broker to ensure you have sufficient coverage if you or a loved one is injured in a motor vehicle collision.

If you have other questions about obtaining services in the auto insurance system, please contact Julie and she will do her best to answer them.

Workplace Safety & Insurance Board (WSIB)

If your injury occurred in the workplace and you’ve been paying WSIB premiums, your therapy may be covered by WSIB. This is a complex system, but we have worked with numerous WSIB claims and we can help you navigate it.

Medavie/Blue Cross Programs

Veterans may have special coverage for their rehabilitation services through Veterans Affairs.    Resettled refugees, protected persons, and refugee claimants have access to the coverage of medical services for a short period of time after their arrival in Canada. These are also complex systems, but we will help you navigate them.

At Sound Expression our clinicians are approved providers through Medavie Blue Cross (programs include Veterans Affairs, RCMP, and Interim Federal Health Program) and through Green Shield Canada.