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BRAIN INJURY SERVICES. CATASTROPHIC INJURIES: IMPORTANT HEALTH CARE AND REHABILITATION ISSUES Robert B. Munroe & Anandi D. Naipaul. Catastrophic Impairment and Statutory Accident Benefits. Personal Injury Group. What is Catastrophic Impairment?.

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brain injury services

BRAIN INJURY SERVICES

CATASTROPHIC INJURIES:

IMPORTANT HEALTH CARE AND REHABILITATION ISSUES

Robert B. Munroe & Anandi D. Naipaul

what is catastrophic impairment
What is Catastrophic Impairment?

Accidents from November 1, 1996- September 30, 2003:

  • Paraplegia or quadriplegia
  • Total and permanent loss of use of both arms
  • Total and permanent loss of use of both an arm and a leg
  • Total loss of vision of both eyes
  • Glasgow Coma Scale score of 9 or less
  • Glasgow Outcome Scale score of 2 or 3 taken more than 6 months after the accident
  • 55% or more impairment of whole person
  • Class 4 Marked Impairment or Class 5 Extreme Impairment due to mental or behavioral disorder

PersonalInjury Group

the expanded definition
The Expanded Definition

For Accidents on or after October 1, 2003:

  • Total and permanent loss of use of both legs
  • Child under 16 may be catastrophic taking into account developmental implications
  • 55% total body impairment time line reduced from 3 years to 2 years
  • Total and permanent loss of use of one or both arms and one or both legs

PersonalInjury Group

analogous impairment
Analogous Impairment
  • Continues to apply to expanded definition
  • Impairment is deemed to be the one most analogous to the impairment that is listed in the AMA Guidelines for the purposes of establishing the 55% whole person impairment rating
  • As indicated above, a child under 16 may be catastrophic taking into account developmental implications for accidents on or after October 1, 2003

PersonalInjury Group

what you need to know
What you need to know
  • Availability of more generous no-fault benefits
  • Entitlement to SABS despite not having a tort claim
  • Valid SABS claim can provide evidence to prove damages in tort claim
  • Funding for reports through SABS

PersonalInjury Group

sabs available to a catastrophically impaired person
SABS Available to a Catastrophically Impaired Person
  • Medical/Rehabilitation up to $1,000,000
  • Attendant Care up to $6,000/mth to maximum of $1,000,000
  • Housekeeping and Home Maintenance up to $100 per week
  • Case Management - included in Med/Rehab cap
  • Expenses of Visitors - all reasonable and necessary expenses
  • Transportation allowances: more generous : ss 14(6)(b); 15(12)(b);24(4)(b)
  • Note: some people have purchased higher “Optional benefits”

PersonalInjury Group

issues in interpretation and proof of catastrophic impairment
Issues in Interpretation and Proof of Catastrophic Impairment
  • Timing of GCS Reading
  • Effects of Drugs and Alcohol on GCS Reading
  • Incomplete Paraplegia/Quadriplegia
  • Psychological Impairment and the AMA Guidelines
  • Which edition of Guidelines to use
  • Criticism of the AMA Guidelines

PersonalInjury Group

time of gcs reading
Time of GCS Reading
  • What is the meaning of “reasonable period of time” for the GCS reading?
  • Young v Liberty Mutual Insurance
    • There is no precise time limit. Reasonableness will depend upon the particular circumstances of each case.

PersonalInjury Group

alcohol readings and gcs score
Alcohol readings and GCS score
  • Holland v Pilot Insurance Company
    • Evidence of medical expert that ingestion of alcohol would have no effect on the GCS was accepted.

PersonalInjury Group

incomplete quadriplegia meets the test
Incomplete Quadriplegia meets the test
  • DiMartini v ING Insurance Co. of Canada
    • Medical expert’s opinion that an insured diagnosed as an incomplete quadriplegic is catastrophically impaired was accepted.

PersonalInjury Group

psychological impairment and guidelines
Psychological Impairment and Guidelines
  • Class 4 Marked Impairment or Class 5 Extreme Impairment due to mental or behavioral disorder
  • Desbiens v. Mordini
    • acceptable to assign percentages to psychological impairments and to combine them with physical impairments to determine if 55% WPI
  • “The recent court and FSCO decisions have carefully considered the definition of catastrophic impairment and have consistently concluded that mental and behavioural impairments can be considered under clause (g).” – Augello v. Economical Insurance (December, 2007)
  • The process for evaluation of the psychological impairment using the AMA Guidelines and the calculation of the percentage of impairment assigned to the impairment requires detailed knowledge of the Guidelines and relevant case law

PersonalInjury Group

which edition of the ama guidelines do you use
Which edition of the AMA Guidelines do you use?

Arguments of Martin Wunder in Kannally v State Farm Mutual to use subsequent editions of the Guidelines:

  • AMA 4th edition refers users to most recent edition
  • AMA 4th edition is superseded by 5th edition which includes methods of pain assessment
  • Application of obsolete medicine leads to absurdity, lack of common sense and breach of reasonable expectations of an insured
  • Use of 5th edition is consistent with sound principles of statutory & contractual interpretation
  • Comment: this approach has not been approved by courts or at FSCO and SABS clearly require use of the AMA 4th edition

PersonalInjury Group

criticism of ama guidelines
Criticism of AMA Guidelines
  • Snushall v Fulsang - obiter
    • Guidelines were developed in the US to adjudicate Worker’s Compensation Claims
    • Laws regarding disability determination are different from work related disability
    • Guidelines are 10 years out of date
    • 4th edition of Guide is no longer in print and difficult to obtain
    • Guide does not take into account possibility of future deterioration leading to 55% impairment

PersonalInjury Group

special considerations in analyzing medical records
Special Considerations in Analyzing Medical Records:
  • Look for evidence of catastrophic impairment
  • Engage medical experts to determine if readings such as GCS score are correct
  • Evidence of cerebral swelling, bruising, and haemorrhaging may indicate whether GCS score was properly measured

PersonalInjury Group

procedural considerations
Procedural Considerations
  • Set out in s. 40 of the Regulation
  • Submit Application for Determination of Catastrophic Impairment to the insurer
  • Consider whether expert opinion is needed
  • Within 30 days of submission, insurer will respond with either approval or referral to CAT IE
  • If insured fails to attend assessment insurer may decide insured not CAT and may stop payment of any CAT benefits
  • If insured attends and insurer fails to give report to insured then insurer must pay CAT benefits until report delivered
  • Insurer must continue attendant care benefits at an amount which assumes CAT until a determination is made by the insurer

PersonalInjury Group

s24 of the sabs
S24 of the SABS
  • Insurers are not obligated to pay for s.24 assessments unless:
    • Pre-approval of the insurer is obtained
  • Exceptions include where:
    • An immediate risk of harm to insured makes pre- approval impractical
    • Assessment is for attendant care needs
    • Determining if Catastrophic impairment if insured is hospitalized or in a long term care facility at time of assessment
    • Preparation of disability certificate if does not exceed $200

PersonalInjury Group

s42 insurer examinations of cat claims
S42 Insurer Examinations of CAT claims
  • Examination only relating to GCS score begins with a “paper” review
  • If examination is “paper” review then report must be completed and given to insured within 10 business days of Notice of Examination
  • If examination required attendance of insured then examination must be completed within 30 business days of Notice of Examination
  • If examination required attendance of insured then report must be given to insured not later than 10 business days after examination completed
  • Insurer must pay for rebuttal report if rebuttal report given to insurer within 80 business days after determination by insurer
  • More generous fee structure for rebuttal reports relating to CAT determination

PersonalInjury Group

case manager must be client focused
Case Manager must be client Focused

Insured has the right to:

  • A case manager who is client focused
  • If insurer has already appointed case manager, to interview case manager to ensure best interest of client is in mind
  • Be aware of all communications between insurer and case manager
  • Ensure that medical services recommended by case manager are client focused
  • To review recommendations of case manager and have input into them

PersonalInjury Group

cat issues and tort claims
CAT issues and tort claims

PersonalInjury Group

exception to general damages deductible
Exception to General Damages Deductible
  • On or after October 1, 2003:
  • If general damages award for pain and suffering is less than $100,000, the deduction is $30,000
  • If the award is greater than $100,000, there is NO deduction
  • Insurance Act section 267.5(8) - (8.2)

PersonalInjury Group

amendments
Amendments
  • Definition revoked in Automobile Tort Claims for injury on or after October 1, 2003
  • Plaintiffs can now sue for health care benefits regardless of whether their injuries are “catastrophic” provided they meet the threshold in s.267.5(5) of the Insurance Act

PersonalInjury Group

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