Intensive Care

Med/Rehab Benefit

Under the new SABS, as of Sept. 1, 2010, a claimant is limited to $50,000 for med/rehab goods and services. Even if additional coverage had been purchased post-Sept. 1, at the time of renewal of his/her auto insurance policy, a claimant would not necessarily have access to the greater amount of coverage if he/she has been diagnosed with a minor injury.

This $50,000 has to cover many potential goods and services – including various therapies, home modifications, medications, assistive devices, hospital bed rental, mobility aids (including wheelchairs, etc.), all of which can very quickly deplete available funds. This does make providers think about what are the essential services and how best to optimize funds available to meet a claimant’s needs. The problem arises when essential services have depleted the $50,000 and the claimant requires ongoing therapy or other goods and services. What then? Right now, it is too early to tell.

In some instances, claimants and/or their legal representatives might hinder the early delivery of essential services because they fear the client might run out of benefits prior to the end of the 104-week period (at which point they may apply for a catastrophic injury determination). This is especially true of cases in which claimants have serious injuries and intend to apply for catastrophic determination at the end of the 104-week mark (e.g. traumatic brain injury, multiple orthopaedic injuries with permanent impairments). Some of these claimants take only the bare minimum in treatment or spread it out over extensive time periods, potentially having a significant impact on recovery.

In other situations, claimants are being denied further treatment. Some report being told by the adjuster that he or she does not think the treatment is warranted. This is another example of adjusters making medical judgments related to the need for ongoing therapy, raising a number of ethical, medical and legal issues.

Under the new SABS, an adjuster must provide a “medical and other reason” for the denial. An adjuster cannot base the decision strictly on what he or she deems to be “not reasonable or necessary.” Nevertheless, more often than not, the latter seems to be the reason given.

Also, the insurer does not have to have an independent examination done when denying an OCF-18. Given that rebuttal reports have been eliminated from the SABS, the claimant’s only recourse after a denial is mediation, thus further delaying therapy.

Independent Examinations (IE)

Under the new SABS, IEs are at the discretion of an adjuster after denying an OCF-18. The findings of the IE are not binding. The cost for IEs does not come out of the med/rehab benefit.

Generally speaking, fewer IEs appear to have been done since Sept. 1, 2010. Those IEs that have been done appear to have been done face-to-face (and not by means of a paper review). This results in the additional cost of travel expenses and travel time for the IE provider.

From an IE provider perspective, the amount of time required to perform an IE may be greater than that required by the treating therapist. This is because the IE provider may have numerous documents to review that the treating therapist does not. Providing IEs requires a certain level of expertise demanded by both the insurance industry and rehab community. However, IEs are capped at $2,000, with the same inclusions as per the assessment cap (as described in Part I of this article: Please see ‘pg 20,21 Auto Part 1′, Canadian Underwriter, January 2011).

Preliminary evidence from the rehab community suggests some potential emerging trends, including the refusal to do IEs within the cap, the breakdown of assessments into component parts (which can then be billed under the cap separately) or adjusters’ use of under-qualified IE providers who agree to do the IE within the $2,000 cap.

Attendant Care Benefit

Under the new SABS, an injured claimant is only eligible for $3,000 per month of attendant care if he or she has sustained non-catastrophic injuries (this increases to $6,000 per month for catastrophic injuries). There are no attendant care benefits for minor injuries sustained in motor vehicle accidents (MVA) occurring on or after Sept. 1, 2010 – even if optional benefits were purchased at renewal of policy post-Sept.1, but before the MVA.

The emerging issue is again in the instance of a serious injury: a claimant is trying to stretch the available dollars over 104 weeks, at which time he/she will apply for a catastrophic designation. Prior to the end of the 104-week period, if the dollars are not enough, the claimant will have to pay out of pocket with a hope to re-coup the money. As a result, some claimants are doing without the care they need, or the responsibility may fall to family members.

A claimant must demonstrate an economic loss for persons providing attendant care, unless the providers have been hired from an outside agency that offers such services. Consider the example of a spouse who is currently at home looking after small children. Let us say he or she now bears the additional burden of providing personal care to his or her spouse. In this example, there would be no demonstrable economic loss. Therefore, there would be no reimbursement, even if additional attendant care benefits were purchased.

In one particular case, a spouse had to take time off work to provide attendant care to his wife. The adjuster reimbursed the spouse for 80% of net income instead of the amount on the Form 1.

What is Being Done?

The Coalition Representing Health Professionals in Automobile Insurance Reform is in ongoing discussions with insurers, the Insurance Bureau of Canada (IBC) and FSCO to address these and other emerging issues. They have jointly produced a ‘Question and Answer’ document based on a 2010 Auto Reform Webcast held in June 2010. It is available on the IBC website. Service providers and adjusters are strongly recommended to access this document to clarify and answer questions that arise in day-to-day practice.

Currently, a shortage of data exists to help guide decision-making and policy development in the insurance industry and the rehab community related to diagnoses, treatment, costs, etc. The insurance industry is attempting to rectify the problem through HCAI.

According to Viivi Riis, senior health advisor to IBC, HCAI is currently in the process of being fully implemented. However, there appears to be a problem with how clinics or providers are using the ICD10-CA codes upon which data gathering related to injury categories would rely. These problems need to be addressed before data gathering can begin.

Willie Handler, senior manager of the automobile insurance policy unit at FSCO, is hopeful HCAI can begin to collect data in 2011. Under this timetable, the first set of data would be available in 2012.

It is hoped that with ongoing discussions and working together in the spirit of cooperation, a number of issues can be resolved to the benefit of the injured claimants. It is hoped these solutions will answer the need of service providers to provide effective and efficient interventions, as well as the need of the insurance industry to contain costs and stabilize the system.