Insurers may be in a "Catch 22" situation in efforts to keep claimants within the limits of the Minor Injury Guideline (MIG). Many insurers have been routinely sending claimants for an insurer examination (IE) to determine if a claimant has a minor injury and should be treated under the MIG. But according to a recent FSCO arbitration, an insurer needs to provide "medical reasons" for denying a benefit and requesting the claimant attend an IE. The SABS require a benefit denial to trigger an IE needed to determine if the claimant belongs in the MIG but also medical reasons which insurers normally obtain through an IE.
In the decision, Kadian Augustin and Unifund Assurance Company [FSCO A12-000452] the arbitrator considered whether or not Ms.
Augustin is allowed to dispute the insurer’s denial of treatment because
she failed to attend an IE. In order to make a
determination the arbitrator needed to consider whether or not the IE was compliant with the SABS.
Unifund wanted to send Ms. Augustin to an IE to
determine if she was within the MIG after receiving
a treatment plan that, if approved, would take her out of the MIG.
Unifund provided the following notice to Ms. Augustin in their
Explanation of Benefits: “Based on our review of the medical
documentation provided to date, we require an assessment by an
independent medical assessor, in order to determine if your impairment
is predominantly a minor injury as described in the Minor Injury
Guideline. Please see the Notice of Examination for further details.”
The arbitrator found that this explanation did not comply with section
38(8) of the SABS because it did not state that Unifund “believes” the
MIG applies, or why. Nor did it state the “medical reasons and all of
the other reasons why the insurer considers any goods or services, or
the proposed costs of them, not to be reasonable and necessary. The
arbitrator noted that it provided no reason, medical or otherwise, explaining why it refused to pay the benefit.
Health care providers have been complaining for some time that benefit denials often to not come with proper explanations regarding the reason for a denial. The government has amended these provisions several times to make it clear that the claimant is entitled to a proper explanation. Now an arbitrator has ruled on the wording. The problem is that no one knows what explanation would satisfy an arbitrator. As well, the arbitrator failed to reconcile that the purpose of the IE is to collect medical information and assist in making entitlement decisions.
The decision can be found here.