Insurers Trying To Keep Claimants in the MIG Will Need Medical Reasons Before an IE
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
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 http://blog.smitiuchinjurylaw.com/wp-content/uploads/2013/11/Augustin-and-Unifund-MIG-medical-reason.pdf
Source: http://williehandler.blogspot.ca
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