Adjusting to SABS: Getting a Grip on Serious Injuries

As a result of Ontario’s new Statutory Accident Benefits Schedule (SABS), which came into effect last September, the adjuster’s role in Ontario auto accident claims has changed. In this issue of Education Forum, we look at some of the knowledge and skills adjusters will now need to bring to these claims.

Under the new SABS, adjusters have more authority to make decisions on a file and a little more time to investigate the validity of a treatment plan. And the lower limit for medical rehabilitation coverage for minor injuries, coupled with the insurer’s duty to keep claimants informed about how that money is being spent, means that adjusters will need to be thorough in determining benefit entitlement and the reasonableness of expenses.

Adjusters now need to develop a broader understanding of serious injuries and how the various facets of injury, assessment, treatment options and coverage fit together.

Knowing major from minor

Adjusting claims under the new SABS first requires understanding the classification of injuries, and in particular the categories of minor and catastrophic injuries.

According to the Minor Injury Guideline (MIG), minor injuries include “sprain, strain, whiplash associated disorder, contusion, abrasion, laceration or subluxation and . . . any clinically associated sequelae to such an injury.” In general, a claimant who has sustained these kinds of injuries is subject to a limit of $3,500 for medical and rehabilitation benefits.

However, if the insured person has a pre-existing medical condition that would prevent the person from achieving maximal recovery from the minor injury if subject to that limit (and if this is supported by compelling evidence from a health practitioner), then the MIG does not apply.

At the other end of the SABS injury classification scale, catastrophic impairments include paraplegia or quadriplegia, the amputation or permanent loss of use of a limb, the total loss of vision in both eyes, certain specified levels of brain impairment, an impairment or combination of impairments resulting in a 55 per cent or more impairment of the whole person, and a class 4 or 5 impairment due to mental or behavioural disorders. Catastrophic impairments are eligible for up to $1 million in coverage.

Although the “cat” category is clearly defined, injuries initially designated under other categories sometimes subsequently develop into conditions that fit the cat definitions. When handling a claim file, all medical information should be gathered and monitored closely, even if the person is not deemed catastrophic at the outset. During the recovery period, psychological and physiological factors can develop that may result in the insured being redefined as catastrophically impaired.

Another important distinction is between an impairment and a disability. An impairment is a physical or psychological effect on a person, whereas a disability is a limit to a person’s social or personal function. Injuries in the cat category lead to impairments that often result in permanent disabilities. Injuries in other categories such as the MIG may not lead to impairments but can result in disabilities.

Tools of the trade

Understanding whether or not a claim legitimately fits within a given injury classification requires understanding basic human anatomy and a range of medical terminology. Where the cat category is concerned, familiarity with guidelines such as the Glasgow Coma Scale, the Glasgow Outcome Scale and the American Medical Association’s Guides to the Evaluation of Permanent Impairment is helpful as well.

Adjusters also need to be familiar with the elements of various medical reports, such as ambulance call reports, clinical notes and records, disability certificates, treatment plans and assessment reports. All medical reports have specific information that must be captured. Knowing the roles of these reports in effective injury management and case resolution will help adjusters to determine whether treatment and rehabilitation expenses incurred are reasonable. The various medical reports in a claims file should present a clear picture of the claimant’s injuries and impairments, the effect of these on the person’s life, the plan to return the person to maximum function, and the benefits the person is eligible to receive.

Where medical reports present conflicting opinions, adjusters need to be prepared to explain why one opinion is preferred over another. This, in turn, may involve asking follow-up questions of health practitioners or medical legal experts.

Examining further

If the medical information on a claim is insufficient and facts need to be confirmed in order to make a decision on a file, an insurer may request an insurer’s examination. For example, if an injury is initially classified as minor but the medical practitioner subsequently decides that it is more serious and requires additional treatment, an insurer’s examination may be set up to verify the revised diagnosis.

Under the new SABS, adjusters have discretion in deciding whether or not an insurer examination is warranted – which means they need to understand what kind of information is required to support decisions in various kinds of injury situations. Adjusters also need to know how to choose the appropriate medical assessor, distinguishing between physiatrists and physiotherapists, psychiatrists and psychologists, neuropsychologists and neurologists – among others.

Looking ahead

Determining benefit entitlement is not just a matter of assessing a claimant’s condition at a given point in time; it also requires looking to the future. For serious injuries, especially catastrophic ones, adjusters need to differentiate between acute and chronic injuries. They must integrate medical information with other actuarial information to establish an appropriate course of action for future rehabilitation.

As they bring all these new medical management skills to bear on a claim, adjusters will need to maintain a focus on understanding the injury and how it affects the person. They will need to develop skills for dealing appropriately with their own emotional reactions to others’ pain and trauma. And finally, throughout the process, they must also maintain the usual good claims-handling practices: gathering all relevant information, handling correspondence carefully, advising the claimant about the process and about the benefits they may be eligible for, and so on.

In the next issue of Claims Canada, Education Forum looks at some of the other knowledge and skills that adjusters working under the new SABS now need.

This article is based on excerpts from the study material in the Understanding Serious Injury series of workshops – a new supplementary training program launching later this year, developed specifically for adjusters by the Insurance Institute of Ontario and the Ontario Insurance Adjusters Association.