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A LOOK AT THE L.A.T.’S DECISION AND RECONSIDERATION OF 18-007991, J.V. AND INTACT INSURANCE COMPANY
Insureds involved in car accidents should have access to accident benefits, regardless of who is at fault. Amongst other things, accident benefits cover the insured’s post-collision treatment cost. They are comparable to collateral benefits you receive through work but have a distinct treatment plan and approval procedure. The treatment provider submits a treatment plan to the insurer explaining the diagnosis and appropriate course of treatment. The insurer reviews the plan and generally responds in one of three ways:
- approve the treatment plan;
- partially approve the treatment plan; or
- deny the treatment plan.
A partially approved treatment plan could mean that not all treatment outlined in the plan is “re asonable and necessary.” It could also mean that the cost of the treatment is too high. In that case, the insurer would agree to pay a portion of the proposed rate. The proposed rate is set out in a “Guideline” that publishes the applicable “minimum” rates of different treating physicians and professionals (See Below).
APPENDIX REVISED RATES AND FEES | ||
---|---|---|
Health Care Profession or Provider | Maximum Hourly Rate except catastrophic impairments | Maximum Hourly Rate catastrophic impairments* |
Chiropractors | $112.81 | $135.36 |
Massage Therapists | $58.19 | $89.07 |
Occupational Therapists | $99.75 | $119.92 |
Physiotherapists | $99.75 | $119.92 |
Podiatrists | $99.75 | $119.92 |
Psychologists and Psychological Associates | $149.61 | $179.29 |
Speech Language Pathologists | $112.22 | $134.17 |
Registered Nurses, Registered Practical Nurses and Nurse Practitioners | $91.43 | $109.24 |
Kinesiologists | $58.19 | $89.07 |
Unregulated Providers | ||
Case Managers | $58.19 | $89.07 |
Family Counsellors | $58.19 | $89.07 |
Psychometrists | $58.19 | $89.07 |
Rehabilitation Counsellors | $58.19 | $89.07 |
Vocational Counsellors | $58.19 | $89.07 |
*This rate applies to all services rendered on or after September 6, 2014 to an insured person whose impairment is | ||
determined to be a catastrophic impairment as defined in the SABS whether such services are rendered before or after such determination is made. |
Despite its visual practicality, the Guideline has its quirks which lead to an alarming trend in treating post-collision mental health ailments. It starts with the lack of available treatment providers, mainly psychologists. To be paid directly by the auto insurer, psychologists or their clinics must be registered through a standard invoice procedure called Health Claims for Insurance (HCAI). Most psychologists are reluctant to do so because of payment delays, reduction in fees and extra paperwork. If you happen to find a psychologist who is registered with HCAI, the practice is often flooded with patients, leaving a wait time upwards of 8-10 months.
To get around this issue, psychologists team up with psychotherapists, counselors or social workers to provide the needed treatment. The psychologist will run the assessment while the psychotherapist, for instance, provides the recommended treatment.
If a service provider is not included in the guideline (such as psychotherapists), it is up to the parties to decide the appropriate rate (the parties being the insurer and the treatment provider). The clinic then looks to the insured to pay the balance on the agreed rate. If the insured does not agree with the rate, it is up to him/her to dispute it. The License Appeals Tribunal (“LAT”), just dealt with one of these disputes in J.V. v Intact (Tribunal File Number: 18-07991/AABS).
J.V. v Intact (Tribunal File Number: 18-07991/AABS)
The plaintiff was in a car accident. He was diagnosed with a psychological condition resulting from the collision. The assessor, presumably a psychologist, suggested cognitive behavioural therapy (CBT). A treatment plan was submitted by a regulated psychotherapist trained to provide CBT.
Since psychotherapists are not mentioned in the guideline, it was up to the parties to decide the appropriate rate. The psychotherapist’s hourly rate for a non-insured patient was $150/hour. Her hourly rate was listed at $149.61 in the treatment plan. The insurer agreed that the treatment was reasonable and necessary but disagreed on the hourly rate. They approved the treatment plan at a rate of $99.75/hour.
Adjudicator Parish noted that psychotherapists were not governed by the guideline but refused to disentitle them from receiving the minimum hourly rates of psychologists where appropriate. She explained:
The adjudicator approached the issue focused on the treatment provided and the provider’s credentials. She explained that both psychologists and psychotherapist may share the necessary credentials to provide specific treatment, in that case, CBT. The value of that treatment should not be lessened by the provider’s title alone.
Since being published, this decision has been mentioned by several lawyers and treatment clinics alike. The hope is that insurers will act accordingly and start to increase treatment rates to reasonable numbers. Notwithstanding, insurers continue to offer rates as low as $58.19 per hour to psychotherapists.
The guideline remains stagnant on the issue, there’s no statutory obligation to increase rates. As stated by the insurer in JV v. Intact, “if the Guideline needs to be updated […] it is the responsibility of the Superintendent to do so.” In other words, the current guideline does nothing to force insurers to offer appropriate rates… so why would they?
There is no doubt that the decision should give confidence to those who wish to dispute the issue; however, disputing a low treatment rate has its own hurdles. It’s evident in this hypothetical:
If the fallout of disputing and obtaining a favorable decision is to have treatment delayed significantly, lawyers work and fees likely never paid and no insurer accountability, why would anyone dispute it? We have to applaud the zealous advocacy in J.V. v. Intact. Despite these factors, they and their client put the issue on paper before the LAT and sacrificed in doing so. Adjudicator Parish approached it logically and confirmed there was merit in theirs and several other insurer’s frustrations. Unfortunately, we continue to be bound by a fractured system used to endorse low arbitrary treatment rates. Pushing the issue before the LAT will hopefully force an adjustment in the Guidelines.
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