Injury claims—part two

In my September 2009 article (BCMJ 2009;51[7]:308) I discussed some aspects of injury claims, including:
• ICBC accident benefits available as part of the basic vehicle insurance regardless of who is at- fault for the accident.
• Settlements obtained by negotiation or litigation of the at-fault party under tort law.

This article will pursue the claims perspective a bit further.

Claims for minor injuries that are expected to resolve within a relatively short time are handled by the Centralized Claims Injury Centre (CCIC). In order to maintain availability on a continuous basis, the ICBC adjusters in this centre work in teams that are closely coordinated by computer in a call-centre environment. Each adjuster on a team can handle any inquiry, task, or duty. If you have a telephone message or conversation with one of the CCIC staff and are given contact information for a callback, you will typically be advised to speak with the A team or the B team. Individual names are not given because all members have immediate computer access to up-to-date information on the claim. You will be able to speak with any member of the handling team and not be hampered by playing telephone tag with any individual.

More complex injuries are handled by an adjuster at one of the Claims Centres. In this case there is usually one adjuster in charge of the claim file and that is the person you would have contact with. Usually this contact is written rather than verbal. Adjusters handle all aspects of the claims including settlement negotiations, and, if necessary, litigation.

When an injured person has a claim for an MVA, he or she calls Dial-a-Claim, which is operational 24/7. Based on the information given at that initial telephone interview, ICBC personnel will refer the claim to CCIC or to a Claims Centre and the claimant is given the appropriate contact information.

Under the no-fault accident benefits, a person is able to attend a physician, chiropractor, or physiotherapist without a referral. Physiotherapy visits without a medical referral are covered for a maximum of 12 visits at the ICBC rates. If the physiotherapist charges more than the ICBC rates, the patient is responsible for paying the difference. ICBC may request the completion of a Physiotherapy Treatment Plan form (CL20) and pay accordingly.

Chiropractic visits may be part of the new pilot program discussed in my September article. In this case, where payment is on a lump sum rather than a per visit basis, there are no additional fees that the patient is required to pay. If the chiropractor has not opted to partake in the new program, the patient may have to make payments to the chiropractor above the ICBC rates.

ICBC considers payment for massage therapy only when it is required and is “essential for the rehabilitation of an insured” and a referral is made by a physician. The treating physician must “diagnose, prescribe treatment (and areas of treatment) and monitor/reassess the insured’s progress in relation to the functional goals defined by the physician.”

It is important for physicians to understand the basic parameters and limitations of insurance coverage. Basic coverage using accident benefits is widely available and is regulated under the Insurance (Vehicle) Act. Adjusters have no discretionary capabilities to make decisions in contravention of this Act. Under the Act there is no provision for private MRIs, alternative health care remedies, hot tubs, and so forth, no matter how much you or your patients may want them.

When a person makes a claim with ICBC, it is standard practice that he or she signs an authorization for the release of medical information. This authorization allows the practitioner to speak with a representative of ICBC or to send a copy of medical records or prepare a narrative report. If there is no signed authorization or it has been revoked, ICBC is still entitled to receive a completed CL19 from the physician under the Insurance (Vehicle) Act.

Should you have any questions, comments, or suggestions for future articles, I would be happy to receive them at DrLaura.Jensen@ICBC.com.

—L.A. Jensen, MD
ICBC 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.