Survey finds insurance companies now rejecting more than 40% of treatment requests
TORONTO, Jan. 19, 2012 /CNW/ - A survey released today reveals that insurance companies in Ontario are now turning down an increasing and alarming percentage of requests for the assessment and treatment of serious (non-minor) injuries sustained by motor vehicle accident victims.
Denying, Delaying and Cutting Off Benefits
The survey of 1,143 rehabilitation providers (889 sole practitioners and 254 company/practice owners) found that 42% of requests for treatment are now being rejected, up from only 11% prior to the government's changes to the insurance system in September, 2010. That's a 282% jump.
The denial rate for initial assessment is now also 42%, compared to 27% a little more than a year ago. The survey was spearheaded by the Alliance of Community Medical and Rehabilitation Providers.
And for those who wish to challenge being turned down by their insurance company, the wait is now at least a year for mediation and in some instances two years for arbitration. "Literature clearly shows that rehabilitation is most effective immediately following the accident. Our concern is that by the time the matter is addressed in dispute resolution, it is simply too late for many of our clients," says Nick Gurevich, President of the Alliance.
The Alliance had requested information about the insurance industry's denial rates from Health Claims for Auto Insurance (HCAI), an initiative of Ontario auto insurers, which transmits claim forms between insurers and health care facilities in Ontario. HCAI turned down this request. "That's why we went ahead with our survey. We feel consumers have a right to this information, yet there's very little transparency in the system," notes Gurevich.
Now Insurance Adjusters Decide Whether You'll Get Treatment
Another so-called 'reform' ushered in by the province now permits insurers to deny assessment and treatment without having to obtain a second medical opinion. That means an insurance adjuster with no medical training now decides whether or not you need the rehabilitation therapy or equipment that a health care professional recommends for you.
The survey found that only about half of the requests for assessment and treatment now being turned down are referred to an independent examination. Prior to the government changes, all such denials had to be referred for a second medical opinion recognizing the fact that adjusters lacked the required education and training to independently rule on such requests.
Other Key Survey Findings
- insurers are now automatically classifying many cases as 'Minor Injury' even though the health care providers have identified the injuries as serious
- survey respondents say more than half of their patients who have been slotted into the 'Minor Injury' category will run out of benefits before they recover
Policyholders Frustrated and Angry
Policyholders who have had an accident are left frustrated and angry when they encounter this response from their insurer. "You've paid the premiums for years. Then when you need the benefits to which you're entitled, they're not there. You have to fight the insurance company every step of the way," says Jennifer Ryan.
Her husband, Andrew, was severely injured when a car hit his bicycle. While covered under his insurance policy, and eligible for $100,000 in benefits, he has had difficulty getting the treatment he needs. "The insurance company has denied many services, and this has stalled his recovery," notes Jennifer. "If Andrew had been treated earlier, he'd be much further ahead today."
Accident Victims Fighting For the Benefits They Thought They Had
She says the insurance company has been willing to fund only about half of the needed services, and the couple has had to turn to the public health system as well as pay out of pocket for therapy not covered by OHIP. She estimates that she spends one or two hours a day fighting for the benefits they thought they had and dealing with the endless challenges and delays posed by the insurance system. "It's a nightmare," she states.
About the Alliance
The Alliance represents approximately 80 companies and about 3,500 health care providers including physiotherapists, occupational therapists, speech language pathologists, chiropractors, psychologists, rehabilitation therapists, social workers, personal support workers and case managers. It is these individuals who are the primary providers of healthcare and rehabilitative services to Ontarians who are injured in automobile accidents.
For further information:
To arrange interviews with accident victims, or with Alliance President Nick Gurevich, contact: