By Jon Mills, C.Psych., ABPP
Since the new MVA laws took effect in September of 2010, patients are routinely and systematically being denied psychological services by insurers, even when clinical intervention is warranted. Many clients who report suffering from emotional distress and clinical symptoms as a direct result of their accidents are being refused psychological intervention they are entitled to receive under the law. Not only is this a grave injustice, but it is also unethical as it is motivated by insurers who exploit the injured based on economic self-interest. What is truly egregious about this practice is that it denies patients the appropriate health care they have a right to for legitimate, substantiated reasons.
Having worked as a clinical psychologist in the post-MVA rehabilitation field for years, I am increasingly dismayed by how the insurance industry can empower non-health-related claims adjudicators to arbitrarily determine the fate of patients’ health care delivery. In too many cases, patients experiencing disabling psychological symptoms such as generalized anxiety, chronic pain, mood disturbance, sleep dysfunction, phobic reactions, traumatic flashbacks, panic attacks and affect dysregulation are callously denied help because their insurer refuses to acknowledge their suffering, instead decreeing that they do not require psychological intervention.
The Limitations of the MIG
MVA clients are being denied their legislated right to health care under the Minor Injury Guideline category, which caps a claimant’s funding at $3,500 for all health care services. If an insurer were to grant a client the right to receive a psychological assessment and/or psychotherapeutic treatment, this would likely push the client out of the MIG category and the insurer would be on the hook to pay for the additional health care costs the client would probably incur.
The MIG category is being applied randomly and as the first line of defence by most claim adjudicators because they are invested in keeping the costs of claims and health care expenditures to a minimum. Despite the fact that psychologists, doctors and regulated health professionals file OCF-18 Treatment and Assessment Plan forms on behalf of their patients, professionally attesting to the authentic need the client has to legitimate health care services, often a claims person who is not even in the health care field can deny necessary intervention. This happens because there are no established criteria, regulating bodies or watchdogs to prevent such unfair and discriminatory practices. Insurance adjudicators invent their own criteria and appeal to arbitrary rules under the MIG category, even when disabling clinical symptoms have been thoroughly documented.
As an example, I recently had a case where an MVA victim – a pedestrian – was hit in a crosswalk and dragged down the street, pinned underneath a minivan, screaming in horror. The claims adjudicator denied her psychological intervention even though she had undergone a psychological consultation where her trauma symptoms were incontestable. When I called to protest on the patient’s behalf, the adjudicator exclaimed, “I don’t know what the patient needs, I’m not a doctor.” “But I AM a doctor!” I replied. “She’s traumatized and needs help.” However, my attempts to intervene were in vain because there is no real appeal process or accountability for adjudicators.
Independent Assessments
Many insurers deny the claimant psychological help under the charade of the MIG category, claiming they have to follow so-called “industry rules” and then sending the patient to the insurer’s hand-picked psychologist who will deliver the desired verdict. Because there is no formal appeal process, insurers get away with sending the client to a “hired gun” who usually finds in favour of the insurer in order to continue to receive more work. This is palpably unethical: the insurer robs patients of the right to consult the health care provider of their choice, and this biased, one-sided approach to psychological assessments from the insurer's perspective completely eliminates the opportunity for independent assessments.
However, such a practice does curtail costs and keep payouts to a minimum. In this way, IME assessments conducted by insurer-appointed assessors are no different from the defunct Designated Assessment Centres, who hired professionals for peanuts but promised them volumes of work in return. Because there is an inherent tendency to please whoever issues your paycheque, in-house assessors are not likely to be particularly sympathetic to patients’ therapeutic needs. And with no appeal process, the client is left out in the cold.
Health care providers need to be vigilant about the psychological impact MVAs have on their patients’ overall health and recovery, and not merely assume that post-accident physical rehabilitation is all that is needed. They should be particularly vociferous in protesting against bias, unethical practices and observed injustices when patient abuse occurs via the withholding of appropriate health care services. The bottom line is that when patients are denied their legitimate right to psychological intervention after experiencing the baneful effects of an MVA, the insurance industry is harming them and contributing to their suffering by refusing psychological services under the pretext of the MIG category. This is inhumane and unethical.
When arbitrary decisions are made by non-health care providers (insurers) to deny treatment based on economic and political self-interest, and when they employ no objective criteria in their decision-making policies, which are governed by subjective caprice, then there is no recourse for accident victims, who are caused to suffer needlessly. Although health providers can advocate for clients, educate them on their rights and recourse possibilities, and encourage them to complain, this often exacerbates their psychological stress and leads to more anxiety and more retaliatory aggression by insurers.
Compounding Health Problems
What insurers fail to realize is that when they deny psychological intervention, including assessments and treatment, they are compounding patients’ health problems and interfering with their ability to function adaptively and ultimately recover from their injuries. This in turn affects their ability to work, participate in family and social life, and perform tasks of daily living, all of which concomitantly contribute to a compromised quality of life. Not only does this unfair, unethical and unwise practice lead to longer recovery times, but it also increases the statistical probability of more disability claims in the future due to protracted health complications and permanent impairments.
The Economics of Early Intervention
Short of civil lawsuits and lobbying efforts to change MVA insurance laws, possible solutions to this unfortunate situation are not readily at hand. As long as there are no objective criteria or accountability processes for insurers to follow, accident victims will continue to be denied psychological intervention despite their suffering. Solutions will be difficult and will require cooperation, goodwill and contributions from all sectors of the MVA industry. Ultimately, in addition to the many arguments for a collaborative and conciliatory approach, an appeal to economics might be the most compelling: insurers who recognize the value of mental health treatment will also curtail the probability of future disability claims. If accident victims get the help they require when they are experiencing psychological distress and clinical symptoms, they are more likely to recover before their conditions become disabilities. This will keep costs down for the insurance industry in the long run, and offer a humane response to those trying to heal and get on with their lives.
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Dr. Jon Mills is a registered psychologist, Diplomate and Fellow in Clinical Psychology and Psychoanalysis with the American Board of Professional Psychology, and an internationally recognized scholar. He is director of Mills Psychology Prof. Corp. and serves many rehabilitation clinics, assessment centres and medical facilities within the GTA. www.MillsPsychology.ca.
