This entry is by Nick White, AB Consultant with Cameron & Associates.

Nick began his career in insurance in 2007 and quickly moved into Accident Benefits where he continues to handle all levels of injury claims. He has championed settlement and dispute resolution projects as well as many training initiatives.

Medical Rehabilitation Limits after September 1, 2010 (Part I)

With the reforms to Bill 198 now comfortably (so to speak) in place both insurers and plaintiffs have developed their own strategies and styles for handling medical rehabilitation limits and the Minor Injury Guideline.   It was no surprise that plaintiff lawyers were quick to chime in on the pitfalls of the new regulations – and that insurers were quick to point out the need for reform to control exploding premiums – but what about claim handlers?

We have all heard and (if you drive in Ontario) experienced your standard policy non-catastrophic medical rehabilitation limit lower from $100,000.00 to $50,000.00 with your premium remaining the same or increasing.  This disparity is the first battle cry of any plaintiff lawyer arguing the reform is flawed, and frankly if you pay premium in this province, you may be inclined to bang the drum with them.

The second complaint regarding medical rehabilitation from any plaintiff lawyer (and possibly claimant) is likely going to be the combining of the insured’s cost of examinations with their scheduled medical rehabilitation limits.  Cost of examinations prior to the reform were not capped, and became a huge bone of contention between insurers, lawyers and other stake holders because of escalating out of control costs and insurance fraud.  Clinics could in essence propose anything and ultimately it was no threat to the claimant’s medical rehabilitation or other scheduled limits.  It also allowed for the tort file to be built on the backs of accident benefits so to speak.  I’m not a litigator, but clearly there is a trend of some plaintiffs (and defence) to simply amass mountains of medical reports in an attempt to sway an arbitrator, judge, jury and so on.

What is a claimant to do?  How does a claimant manage their medical rehabilitation and substantiate their on going disability?

Carefully.   Not only does the plaintiff lawyer or claimant have to monitor these limits, but the insurer too needs to look at the facts of every file and do something that has been lost in recent years: Call claimant, call the lawyer, call the doctor.

If Mrs. Insured has had a severe accident, and right now has to wait two years to determine she may or may not have sustained a catastrophic impairment. Mrs. Insured (and her lawyer) must work with the insurer and visa versa.  The lawyer cannot send her to a gamut of assessments only to find that $20,000.00 in medical rehabilitation limits have been squandered.

The adjuster cannot blanket approve all treatment only to be left with a badly impaired claimant collecting specified benefits, such are IRB or CareGiver, long after her treatment dollars are gone.  The two need to call each other. The adjuster must always keep in mind that we are seeking to lessen the effects of disability to help the claimant recover and reduce the duration of the claim.   It cannot be done by aggressively denying treatment nor can it be done by blindly approving every proposal that crosses the desk.