ICBC medical claims coverage

This is the third in a series of articles on BC physicians and ICBC working together to resolve bodily injuries caused in motor vehicle crashes.

In my first article I invited physicians to e-mail me at martin.ray@icbc.com. Dr Ralph Jones in Chilliwack, who has a general practice and specializes in mental health care, recently asked me to clarify ICBC’s responsibilities for medical coverage in order to understand why some medical claims are paid by ICBC and others are not.

1. Does ICBC’s coverage depend on whether the patient was at fault in the crash?

2. Will ICBC medical benefits continue if the patient is in a legal dispute with ICBC?

3. It seems that a negotiation occurs each time between the patient and ICBC. Why is that?

4. As with WorkSafeBC, are there any ICBC expedited appointments (for example, CT scans, nerve conduction)?

5. How many physiotherapy, massage, or chiropractic treatments are covered by ICBC?

Managing ICBC bodily injury claims can be frustrating for physicians—Dr Jones and me included—who do not fully understand the regulations and legislation governing ICBC claims.

A better understanding of the ICBC system will go a long way in assisting physicians in their care of injured patients. To help us out, I contacted ICBC’s senior staff in the Bodily Injury Services Department.

The ICBC system

BC is the only jurisdiction in Canada that operates in a full tort system and provides no-fault accident benefits according to the regulations pursuant to the Insurance (Motor Vehicle) Act of BC.

Under BC’s tort system, the not-at-fault injured party is entitled to take legal action against the at-fault party to recover damages for loss of income, out-of-pocket expenses, pain and suffering, and other potential losses of income.

Liability

Adjudication of a claim may be held up when the question of who was at fault for the crash is contentious or there is a serious claim. ICBC may not be able to admit liability if the claim against the driver is likely to exceed that motorist’s policy limits or if the motorist has excess liability coverage through another company.

ICBC accident benefits

Regardless of who is at fault, ICBC may provide accident benefits to cover medical and rehabilitation expenses up to a maximum of $150 000. ICBC’s accident benefits are intended to cover the claimant’s medical needs only when no other benefits are available to him or her. ICBC will not cover medical and rehabilitation services for a claimant if they are covered by another source such as private disability plans or WorkSafeBC. Medical services are not required to be paid in an amount above the MSP fee. Eligible expenses include medical and dental treatments, attendant care, rehabilitation services, medical equipment, and hospital care. Also available are income-loss benefits up to a maximum of $300 per week and homemaker services up to $145 per week.

Injured patients who are not at fault will usually make both a claim for no-fault accident benefits (commonly called Part 7 benefits by ICBC adjusters) and a tort claim (Part 6 coverage) against the liable motorist.

What therapy is covered?

ICBC’s regulations state that physiotherapy treatments are limited to 12 visits under its accident-benefits coverage unless the general practitioner or ICBC’s medical advisor advise that the patient requires more treatment.

However, there are no limits on the number of chiropractic treatments that ICBC will cover.

Massage therapy is not covered under ICBC’s accident benefits, except at ICBC’s sole discretion. Adjusters generally will not pay for massage therapy under the tort claim unless the physician considers it essential for the patient’s rehabilitation. In some instances, ICBC will pay for 12 visits at $23 per session during the first 8 weeks and commencing from the date of injury.

Alternative therapy and medication

ICBC’s accident benefits do not cover any type of alternative therapy or treatment. Payment for unproven therapy is discouraged under tort claims. ICBC looks for evidence-based recovery practices and techniques that support effective, cost-efficient care.

Expedited referrals and investigations

ICBC will only pay the standard MSP fee for a claimant’s medical services. There is no mechanism available in ICBC’s legislation to support expedited medical referrals or investigations. Unlike WorkSafeBC, ICBC is not exempt from the Canada Health Act.

In appropriate situations, an out-of-pocket tort advance may be paid directly to the claimant but not to the provider. This type of advance may be used to access private consultations, investigations, or therapies that are not covered under ICBC’s accident benefits.

Litigation and continued medical benefits

Accident benefits for medical care are provided by ICBC regardless of whether legal proceedings have been initiated in a claim.

Coordinated care for rehabilitation

ICBC may provide funding for multidisciplinary treatment and return-to-work planning. This requires consultation with the ICBC adjuster and must be pre-approved.

Serious injury

In more serious injuries, the adjuster may facilitate the patient’s recovery through ICBC’s Hospital Discharge Program. An ICBC rehabilitation coordinator will work with health care providers to help the patient make the transition from hospital care to home care. ICBC will fund community support services and medical equipment up to a maximum cost of $150 000.

Denied coverage

Benefits may not be payable in a situation such as suicide or attempted suicide, driving while prohibited, or when the injury or death is caused by unrelated sickness or death.

WorkSafeBC

WorkSafeBC is a primary insurer. In most MVAs involving employees, WorkSafeBC will become the designated insurer and a First Visit Claim (Form 8) will need to be filed by the physician. If the injured person is considered to be at work at the time of the injury, he or she is eligible to file a claim with WorkSafeBC. However, if the other liable person is also working at the time of the crash, the worker is barred from pursuing a tort claim against the other worker or their employer, and coverage will revert back to WorkSafeBC.

Only WorkSafeBC can determine if the claimant is eligible for WorkSafeBC coverage and benefits. ICBC has a senior claims examiner at WorkSafeBC who works with a senior WorkSafeBC adjudicator to facilitate prompt determinations on these claims.

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Things get difficult when we do not fully understand the rules, regulations, and laws affecting the care of patients injured in motor vehicle crashes.

Continued dialogue will assist us in moving toward creating a better understanding between ICBC and the physicians of British Columbia and, in turn, achieve our goal for effective management of bodily injury claims. Your questions and comments are welcomed.

—Martin Ray, MD