On Thursday morning, the wreckage of an automobile demolished in a dreadful accident is sitting on Nathan Phillips Square in front of City Hall in Toronto. It’s a painful reminder that each year approximately 12,000 people sustain serious injuries from automobile accidents. Until now though, accident victims thought they could count on the province to foot the bill for multiple therapies for support and care, some for the rest of their lives.
But that could change within the next few weeks.
That’s when Finance Minister Dwight Duncan decides whether or not to adopt the recommendations of the Financial Services Commission of Ontario (FSCO) as outlined in their report of March 31. It’s recommendation #22 that’s troubling to The Alliance of Community Medical and Rehabilitation Providers, a coalition of 43 organizations in Ontario providing clinical services to victims of motor vehicle accidents.
It suggests reducing the cap for medical and rehabilitation benefits for non-catastrophic claims to $25,000 and introducing a $100,000 optional medical and rehabilitation benefit along with the existing $1 million optional benefit.
Right now, the existing cap on medical and rehabilitation benefits is $100,000 for auto accident claimants with injuries that are not considered catastrophic. Those with catastrophic injuries can access up to $1 million in medical and rehabilitation goods and services. In addition, consumers are currently able to purchase $1 million in optional medical, rehabilitation and attendant care benefits coverage.
FSCO argues that a reduced mandatory cap for those with non-catastrophic injuries would provide consumers with more choice and would allow them to customize coverage according to their needs.
“The insurance industry has proposed that a reduced cap of $25,000 would adequately meet the needs of many consumers. Consumers that feel they need a higher level of coverage could be provided the option of purchasing $100,000 in medical and rehabilitation benefits to cover non-catastrophic injuries.”
So how is a “catastrophic impairment” defined?
Permanent injuries such as quadriplegia and paraplegia, limb amputation, and loss of vision in both eyes are considered “catastrophic impairments.” In the case of a brain injury, the Glasgow Coma Scale and the Glasgow Outcome Scale are used to determine the extent of impairment.
Patients with a score of 9 or less on the Glasgow Coma scale, which measures eye opening, motor response and verbal response, are said to be in coma and would be considered to have a catastrophic impairment; patients with a score of 2 (Vegetative State – Unable to interact with environment; unresponsive) or 3 (Severe Disability – Able to follow commands/ unable to live independently) on the Glasgow Outcome Scale would be considered to have a catastrophic impairment.
So under FSCO’s recommendation, if you’re in an accident that leaves you in a coma, vegetative state or severely disabled you’d qualify for $100,000 in benefits. But if you’re moderately disabled, able to make a good recovery or not in coma you’d be considered a non-catastrophic claimant and only entitled to $25,000 in benefits.
“With only $25,000 in medical rehabilitation benefits, these individuals will not be able to get the help they need,” said Patricia Howell, spokesperson for the Alliance of Community Medical & Rehabilitation Providers. “$25,000 may cover a wheelchair, ramps to the home and a short period of nursing care. It will in no way cover the multiple therapies that these individuals need over years to return to independent living, school and work.”
The Alliance estimates that the proposed benefit cuts could result in up to $1 billion in cost savings for insurers. “Yet there is nothing in FSCO’s recommendations that would mandate a corresponding reduction in premiums. Moreover, the estimated savings for the insurance industry will result in a corresponding increase in costs for the health care system as accident benefit victims turn to the public health system for help, amounting to a transfer of costs from insurance companies to the public health care system.”
Howell added, “This seems unreasonable given that the insurance industry is profitable even in this recessionary time.”
In a May 26 article in the Insurance Journal, Insurance Bureau of Canada (IBC) President and CEO Don Forgeron charged: “This group of rehabilitation providers is misleading the public with false accusations that serve no purpose but to further their own financial interest. The auto insurance system needs to put consumers first. The only acceptable priority is an affordable system that also ensures accident victims get back to health as quickly and effectively as possible.”
The IBC accepts that “Ontario auto insurance is in crisis,” but points out that part of the cause is that the “cost of no fault health care services has gone up more than 40 percent in the past four years, and over the past 12 months, these cost increases have been accelerating. And not enough of this is going to treatment. For every dollar spent on therapy, another 60 cents goes to providers conducting assessments.”
Forgeron added: “Other provinces have much lower accident benefit limits than Ontario. These systems work well and accident victims return to health more quickly than they do in Ontario. Despite the alarm raised by some rehabilitation providers in the system, the vast majority of people injured in car collisions suffer sprain and strain injuries and simple fractures. For these people, C$25,000 [US$22,127] is more than enough to restore them to full health. For those who need more, we have called for provisions to be in place to ensure they get more. The goal is the right amount of treatment for everybody.”
The IBC also noted that “Ontario has the most generous auto insurance system in North America, and Ontario drivers pay at least 25 percent more for auto insurance than drivers elsewhere in Canada. Despite that fact, there is no evidence that accident victims in Ontario are getting any better any faster than those in other provinces.
“Contrary to accusations from these rehabilitation providers, reducing Ontario’s medical rehabilitation limit will not transfer costs from insurers to the public health system. The province already collects C$142 million [US$125.65 million] a year from insurers to compensate for the cost to the public system of treating auto collision victims.”
Still, the Alliance is asking the Finance Minister to at least maintain the $100,000 accident benefit coverage for catastrophic and non-catastrophic injuries. But ideally, they say, the benefit should be raised to $240,000 to reflect the increase in the provincial health care budget since the $100,000 cap was implemented in 1996.
While Ontario NDP leader Andrea Horwath supports maintaining the $100,000 accident benefit coverage, she won’t back the Alliance’s recommendation to raise the cap to $240,000 to help cover the costs of seriously injured crash victims.
“The needs of people with acquired brain injuries are not going to be met by reducing the med rehab benefits in the standard auto insurance policy from $100,000 to $25,000,” said John Kumpf, executive director Ontario Brain Injury Association. “When they run out of insurance dollars, they’ll show up in the ER’s.”
When that happens, said Dr. Donna Ouchterlony, medical director, St. Michael’s Brain Injury Clinic, “The health care system won’t be able to cope with the flood of victims that will land on the system.” Many Ontarians wrongly believe that OHIP will pick up all of their rehabilitation needs. In reality, the public system only funds about 10 per cent of the short term rehabilitation services rendered in Ontario.
“And it takes a long time to get over the devastation caused by a brain injury,” she said.
Even though it is possible for Ontarians to purchase optional insurance coverage, most are unaware that this option is available to them; others assume that the government is going to pay for their rehabilitation, so they don’t bother to buy more insurance coverage.
“They’re going to think $25,000 is a huge amount,” said Ouchterlony, who frequently sees patients who run out of funding with the $100,000 cap. “How could I possibly need more than that. And yet an electric wheelchair costs $25,000.”
Ouchterlony added: “Right now home services are rationed. People don’t know that until they’re injured. Some of these services are so rationed that we don’t even refer to them. So the statistics are reflecting the problem in a very small way.”
Ouchterlony warned that we’re headed into a two tier system.
“It’s going to be the rich that can afford the rehabilitation,” she said. “The middle class and the poor will get very inadequate rehabilitation and only after they’ve waited a very long time.”
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