CAP - Uninsured Treatment and Medical
Expenses and Out of Pocket Expenses
(Sections 4.06 and 4.07 of the Transfused and Hemophiliac
HCV Plans)
Revised - October, 2010
Amended Court Approved Protocol
General Provisions
1. For the purpose of this CAP, Treating Physician
means a medical doctor who is or was treating the
HCV Infected Person in respect of his/her HCV infection
or conditions due to his/her infection with HCV.
2. The Administrator shall process a claim for
uninsured treatment and medical expenses or a claim
for out-of-pocket expenses either:
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a)
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one time per Claimant per calendar
year if the total amount claimed does not exceed
$250; or |
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b)
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at any time the total amount claimed
exceeds $250. |
Treatment and Medical Expenses
3. In consultation with a physician(s) in one or
more of the medical specialties listed on Tran 2/Hemo
2 Form ("HCV Medical Specialist") the
Administrator shall compile a list of medications
and treatments which are recommended or prescribed
for treatment of HCV and for conditions due to the
infection with HCV which are generally accepted
by the medical community (the "HCV Medication
List"). This list shall be periodically updated
at the Administrator's discretion.
4. The Administrator may accept a completed Gen
3 Form accompanied by receipts as proof of medical
expenses incurred for any of the items on the HCV
Medication List, except where:
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(a)
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the total claimed for medical
expenses on any one application exceeds $250
(excluding the costs of Compensable HCV Drug
Therapy); |
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(b)
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the level of medical expenses
claimed is inconsistent with the HCV Infected
Person's overall application or disease level
(eg: a person who is at Level 1 and has a negative
PCR test claiming for significant medical expenses);
or |
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(c)
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for any other reason, the Administrator
requires the confirmation of the Treating Physician
that the treatments or medications were prescribed
or recommended as treatment or medication for
the HCV infection or conditions due to the infection
with HCV. |
5. Where one of the exceptions described above
applies, or where there are items for which a claim
is made but no receipts are available, the Administrator
shall require the Claimant to supply a form completed
by a Treating Physician confirming that he/she prescribed
or recommended the claimed items as treatment or
medication for the HCV Infected Person for his/her
HCV infection or conditions due to the infection
with HCV.
6. Where reimbursement is claimed for items which
are not on the HCV Medication List, the Administrator
shall require the Claimant to supply a form completed
by the HCV Infected Person's Treating Physician
confirming that he/she prescribed or recommended
the treatment or medications for treatment of the
HCV infection or conditions due to the infection
with HCV. If the Treating Physician is an HCV Medical
Specialist, the Treating Physician must confirm
that the treatments or medications prescribed or
recommended are generally accepted by the medical
community for the treatment of HCV or conditions
due to the infection with HCV. If the Treating Physician
is not an HCV Medical Specialist, the Administrator
shall consult an HCV Medical Specialist to determine
whether the items are generally accepted by the
medical community for the treatment of HCV or conditions
due to the infection with HCV.
Out-of-Pocket Expenses
7. The Administrator may accept a completed Gen
3 Form as proof
of out-of-pocket expenses due to HCV infection or
conditions due to the infection with HCV, except
where:
(a) |
the level of expenses claimed
is inconsistent with the HCV Infected Person's
overall application or disease level (eg: a
person who lives in a major centre claiming
travel costs to doctors appointments or a person
who is at Level 1 and has a negative PCR test
claiming for frequent appointments with doctors);
or |
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for any other reason, the Administrator
requires confirmation of the Treating Physician
the expenses were incurred due to the HCV infection
or conditions due to the infection with HCV. |
8. Where one of the exceptions described in paragraph 7 applies, the Administrator shall:
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(a)
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require the Claimant to supply
a form completed by the Treating Physician confirming
that the HCV Infected Person had to incur the
expense in order to seek medical advice or treatment
for HCV or conditions due to the infection with
HCV; |
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(b)
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in the event the item for which
reimbursement claimed is such that it is not
amenable to confirmation by the Treating Physician,
require such additional evidence as the Administrator
considers appropriate; and |
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(c)
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if necessary, consult an HCV Medical
Specialist (if the Treating Physician is not
an HCV Medical Specialist) to advise whether
the treatment or medication to which the expenses
relate are generally accepted by the medical
community for the treatment of HCV or conditions
due to the infection with HCV. |
9. Where the exceptions described in paragraph 7 do not apply and the Claimant provides receipts for the items claimed, the Administrator shall authorize their reimbursement.
10. Where the exceptions in paragraph 7 do not apply and there are items claimed for which the Claimant does not provide receipts, the Administrator may authorize the reimbursement of a reasonable amount consistent with the overall application and the disease level of the HCV Infected Person.
11. In all cases, for expenses which are covered by the Treasury Board of Canada Secretariat Travel Directive, the amount stipulated in the Directive shall be the maximum amount which may be reimbursed.
12. The Administrator shall pay a reasonable amount
on account of fees to a Treating Physician for Forms
completed on account of a claim for compensation.
In assessing a reasonable amount for fees, the Administrator
shall have regard to the BCMA position on reasonable
fees as stipulated in the letter from the BCMA dated
June 15, 2000, after indexing to present day dollars.
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