Injury claims—part one

In previous articles I have discussed some aspects of the medical management of injuries sustained in motor vehicle accidents (MVAs). I plan to use the next few articles to discuss MVA-related injuries from an insurance perspective as it relates to injury claims.

ICBC provides some of the best basic auto insurance coverage in the country. It is helpful for physicians to understand some of the basic parameters of this coverage as it pertains to injuries their patients have suffered.
In BC, ICBC is the only insurance provider for basic vehicle insurance. Optional insurance may be obtained from ICBC or alternate insurers. 

Accident benefits
Under Part 7 of the Insurance (Vehicle) Act, basic insurance from ICBC covers accident benefits for injuries sustained in MVAs, and this includes benefits for medical and dental care, rehabilitation, disability, funeral, and death benefits. Customers have access to accident benefits regardless of who is found to be at fault for the collision. If there are permanent injuries, costs for attendant care, specialized aids, and vocational training may be provided, where appropriate.

Customers have 90 days from the date of the accident in which to complete the application for benefits. Usually the injury/disability must be evident within the first 20 days after the MVA. Physiotherapy and chiropractic treatments are typically undertaken within 8 weeks of the MVA, when they are most beneficial.

ICBC and the BC Chiropractic Association have recently negotiated a lump-sum payment system that no longer compensates on a “per visit” basis. The chiropractor is paid $150 for submission of a completed initial report and one or two treatments within 2 weeks. 

Alternatively, if the patient is treated three or more times over more than 2 weeks, the initial payment is $800 with a further $100 after submission of a completed Discharge Report. If treatment extends beyond 12 weeks, a Progress Report must be submitted. In addition, the chiropractor will participate in at least one 15-minute telephone consultation per patient at ICBC’s request. Participation in the new lump-sum payment system is optional for chiropractors and patients.

When treatment by a registered massage therapist is deemed to be “essential for the rehabilitation of the insured,” a maximum of 12 visits within the first 8 weeks of the MVA may be covered when the physician recommends the treatment and monitors the progress.

What is covered?
Accident benefits are payable for medical and rehabilitation expenses up to $150 000. For insured medical services, payments are made according to the MSP Fee Schedule. Payments for alternative therapies are not reimbursed. Under the Act, there is no provision for payment of expedited or private medical services and investigations. 

Payments for pain and suffering and loss of enjoyment of life are not covered under accident benefits. Accident benefits from ICBC do not cover benefits that are available to the claimant through private insurance, extended health benefits, and WorkSafeBC.

Who is covered?
Accident benefits are also available to any injured party with a valid BC driver’s licence, any household member of the owner of a vehicle licensed and insured in BC, any passenger riding in a vehicle licensed and insured in BC, and any pedestrian or cyclist that collides with a vehicle licensed and insured in BC.

Settlement payments
If the claimant is determined to be not at fault for the collision, there may be settlement payments from the third party liability coverage of the at-fault party’s insurance. These may pay for medical expenses beyond those covered in the accident benefits and may provide compensation for pain and suffering. Under the provincial tort system, the not-at-fault injured party may negotiate a settlement with ICBC or undertake legal action against (i.e., sue) the at-fault party to recover expenses, compensation for pain and suffering, and potential losses of income.

The ICBC process
When a collision occurs, ICBC is reachable on a 24/7 basis through Dial-a-Claim. After a claim is reported, one of two things will happen. The ICBC representative will either direct the claimant to an approved vehicle repair facility or arrange an appointment with an adjuster and estimator at an ICBC Claim Centre. The adjuster will provide verbal and written information on entitlements and benefits and may provide the claimant with a claims plan “to-do” list. 

—L.A. Jensen, MD
Medical Community Liaison

The opinions expressed in this article are those of the author and do not necessarily represent the position of the Insurance Corporation of British Columbia.