Early Intervention The New Paradigm in CTP Claims. Presented by Roberto Clemente, Partner

Transcription

1 Early Intervention The New Paradigm in CTP Claims Presented by Roberto Clemente, Partner

2 Introduction In an ideal world early intervention in CTP claims is optimum to health outcomes. Early intervention as a concept has gathered momentum in the CTP arena since the introduction of privatisation on 1 July From that date four well known insurers commenced provision of CTP Insurance in South Australia, namely AAMI, Allianz, QBE and SGIC. Advocates for early intervention from the insurance side of the fence would perhaps suggest that early intervention is stifled where claimants are legally represented due to a variety of factors including: Lawyers impacting upon the ability of insurers to properly manage injuries; Lawyers not encouraging recovery from injury and fostering over servicing; Lawyers focusing on adversarial strategies rather than injury management. The reality is that the vast majority of plaintiff representatives seek to recover reasonable compensation for their clients at the earliest opportunity. Representation is now more important than it has ever been for claimants given the complexities of the current Scheme including the need for familiarity with: Notice requirements under Section 126A of the Motor Vehicles Act 1959 (SA) (including the submission of an Injury Claim Form); The Regulations to the Civil Liability Act 1936 (SA) (including the Schedule 1 Injury Scale); AMA 5 (which is now a key component towards arriving at an appropriate ISV).

3 The Adversarial System The reality is that neither insurers nor lawyers are best placed to facilitate optimum health outcomes for claimants. This is best left to medical and allied health professionals. Lawyers and insurers are in the business of litigation. For lawyers, the best outcome is achieving the highest possible damages assessment for a client and for an insurer the best outcome would be to achieve settlements in as many claims as possible, based upon an ISV of 7 or less (assuming a potential claim for future loss of earning capacity). The objectives of lawyers and insurers are not congruent with those of early intervention. Unfortunately, in the last 21 months I have seen many poor health outcomes in the early stages of claims for various claimants. In my observation, this has been as a result of an overzealous and heavy handed approach by insurers, which often has no resemblance to a proper early intervention approach. Most of my days as a plaintiff lawyer are now heavily consumed dealing with issues arising from insurers failing to agree to attend to payment of reasonable treatment expenses on an interim and without prejudice basis or failing to agree to a reasonable request for an interim payment. In the alternative, approvals are often taking a long period of time, causing claimants considerable stress. Further compounding this problem are frequent requests from insurers for records and reports, which are often not directly relevant to the matters in issue, to approve simple forms of treatment (including physiotherapy, consultation with a spinal surgeon, radiological investigations, etc.).

4 The Adversarial System - continued As a plaintiff lawyer my ability to obtain agreement for payment of medical expenses and interim payments is being impacted upon by the daily bombardment of communications received from insurers (by telephone, letter and ) along the following lines: Failure to satisfy the notice requirements for a claim where a medical certificate has not been obtained pursuant to Section 126A (2) (c) (ii) of the Motor Vehicles Act 1959 (SA), sometimes in cases involving serious injury where the injured claimant was hospitalised for a period of weeks; Requests for pre-accident medical records where a simple request is made for approval for treatment with a specialist spinal surgeon (where there is no basis on the evidence for a causation issue to be raised); Arranging of independent medical examinations in response to a request for funding of treatment such as participation in a pain clinic (where the medico-legal report will often cost more than the course of treatment); Frequent requests for general updates in circumstances where it is not cost effective for the lawyer to provide such general updates (given there is no certainty that the thresholds for non-economic loss and future economic loss will be met); Arranging of Activities of Daily Living Assessments in response to a claimant seeking reimbursement for a handful of cleaning and gardening expenses (with the cost of the assessment far exceeding the cost of the expenses being claimed). Due to time constraints, the above is not an exhaustive list of difficulties that plaintiff lawyers confront on a daily basis in attempting to secure interim benefits for their clients.

5 The Adversarial System - continued There is presently an unhealthy focus by insurers upon pre-accident medical records and independent medical examinations as providing the necessary evidence for what is reasonably required by a claimant. Often several months will pass whilst this evidence is being gathered before answers are provided to reasonable requests. This leads to delay in stability of injuries, the ability for an ISV assessment to be conducted and for final damages to be assessed. Many claimants have a very good treatment team in place (including general practitioners, physiotherapists, orthopaedic surgeons and psychiatrists). Often, the opinions of these treating experts are ignored and non-directly relevant records are requested and independent medical examinations are arranged, before consideration is given to approving treatment. Often it appears to me that the insurer is doing nothing more than buying time. This approach often leads to stress, anxiety and importantly a delay in the progress of a claimant towards stability. I raise the above out of concern for the unnecessary costs been generated, both in terms of excessive communications and costly expert reports being generated, where often the exposure of the insurer would be the same or less by simply approving reasonable treatment (supported by the claimant s medical and allied health treatment providers). It should not be overlooked that when an insurer approves funding for treatment it is generally on an interim and without prejudice basis, and if a genuine issue relating to causation later becomes apparent, the insurer could seek a credit in relation to payment of non-accident related treatment expenses.

6 Case Example 1 Male claimant aged in his late 30 s. Employed as a Full Time Panel Beater at the time of the accident. As a result of a rear end accident he has sustained injuries including at the C6 level of the cervical spine. The claimant suffers a knife like feeling between the shoulder blades, tingling involving the left thumb and index finger and pain at the back of the head. The claimant was referred to a neurosurgeon and funding for this was not agreed to by the insurer and treatment could not proceed as the claimant could not afford the private consultation. The claimant has been totally incapacitated from employment since the collision in May The claim is now very much at a stalemate due to the insurer s refusal to fund treatment with the neurosurgeon. The insurer has instead offered to fund an exercise programme, in circumstances where such treatment would appear to be totally inappropriate and inconsistent with the recommendations of his treating doctors.

7 Case Example 2 This case involves a male claimant aged 45 who was involved in an accident in July He has sustained multiple injuries including an L5/S1 annular tear, L4/5 lateral disc protrusion and a cervical spine injury. His general pre-accident health was excellent. Prior to the accident he had worked with a metal fabrication company for more than 20 years. His pre-accident employment role was as a team leader and his duties involved lifting, cleaning metal, stacking and forklift driving. As a result of his injuries he has not been able to return to work due to the fact that his pre-injury employer will not accept him back at work unless he can perform full and unrestricted duties, which is not possible with his physical restrictions. It is likely that his pre-accident employment will shortly be terminated due to the longevity of the period of incapacity. The claimant has recently been referred to a specialist for the purpose of rhizolysis and funding for this treatment has been refused by the insurer. Furthermore, the insurer has also recently refused a request for an interim payment, despite the claimant not having worked for his pre-accident employer since December The difficulty this claimant faces is that his claim cannot progress until his injuries are stabilised (after the completion of his treatment) and his work capacity is unlikely to improve without further treatment. The insurer is refusing to fund further treatment and an interim payment as they are of the view there is insufficient medical evidence to confirm that the claimant s injuries and ongoing incapacity for work relate to the subject accident (despite there being a significant body of evidence suggesting otherwise).

8 Case Example 3 Female claimant aged in her early 70 s at the time of accident in July Struck down by a vehicle whilst travelling on foot in the carpark of a Shopping Centre. The claimant was hospitalised in Royal Adelaide Hospital for 10 days. She was subsequently hospitalised in Hampstead Rehabilitation Centre for approximately 4 weeks. Her injuries included fracture of the proximal portion of the left tibia and distal portion of the left fibula, fracture to the left ankle, irritation of the right leg sciatic nerve, bruising to the left side of the face and general anxiety. In response to a request for funding of the cost of a ramp at the front and rear of the claimant s home, the insurer requested the claimant s pre-accident medical records (which bear no resemblance whatsoever to the serious injuries she sustained in the collision and the need for the ramp). The above ramp was installed by the claimant s local council who generously partially subsidised the purchase of the ramp. Instead of promptly paying the balance for the ramp, the insurer arranged an ADL assessment and requested the pre-accident records (in circumstances where the surrounding evidence clearly points to the claimant s severe injuries creating the need for the ramp).

9 Case Example 4 A female claimant in her mid-20 s was involved in an accident in February Several months before the accident she had undergone a microdiscectomy to the lumbar spine with a successful outcome. She had been employed as a part- time Service Support Officer in the public sector. At the time the accident intervened she had been cleared to work 25 hours per week and was about to return to social netball. As a result of her involvement in the collision she sustained multiple injuries including a worsening of her lumbar spine condition, to the point where she now requires a spinal fusion. She has largely been totally incapacitated since the collision and has suffered significant financial loss. The insurer has been extremely resistant in relation to requests for interim payments, insisting upon an enormous amount of documentary evidence for the claimant to demonstrate financial hardship. The insurer has only agreed to two very small interim payments (much less that 80% of her Economic Loss to date), despite the insurer being aware that at one point after the collision the claimant was evicted from her home and was sleeping in the back of a shop premises, such was her financial hardship. The insurer in presently insisting upon an ADL assessment to approve ongoing domestic assistance even though the treating spinal surgeon has recommended a spinal fusion and ongoing domestic support.

10 Dispute Resolution CTP Regulator Rules When difficulties arise relating to funding concerning treatment expenses and interim payments, it is often difficult to progress a claim towards formulation and final assessment of damages. Can any assistance be gained by enforcement of the CTP Regulator Rules in these circumstances? One of the functions of the CTP Regulator as set out in Section 5 of the Compulsory Third Party Insurance Regulation Act 2016 (SA) is to make rules relating to a number of areas including: 1. Management of claims; 2. Dispute resolution. The CTP Regulator Rules themselves set out various obligations on the part of insurers as well as processes to be followed for dispute resolution. The obligations of an insurer are set out at Rule 3 and include: 1. Dealing as expeditiously as possible with claims. 2. Ensuring its processes for dealing with claims are efficient, cost effective and in accordance with the law. 3. Encourage early and appropriate treatment and rehabilitation for people who suffer injuries. 4. Maintain service standards and business practices consistent to all customers.

11 Dispute Resolution CTP Regulator Rules - continued Rule 3.5 sets out service levels required by insurers, which include: 1. Providing assistance to claimants to ensure they are able to comply with claim lodgement requirements. 2. Focus on the early assessment of claims. 3. Make fair and reasonable assessments of claims in accordance with the law. 4. Have a sound and clear process to deal with complaints. Rule 13 deals with disputed claims and provides for: 1. Internal dispute resolution. 2. Conciliation.

12 IDR Processes Rule provides that: - If a claimant disagrees with a determination made by an approved insurer in relation to a claim, the claimant may ask to have that decision referred to the approved insurer s IDR process. Rule requires the IDR process to comply with standards and requirements made or approved by ASIC. It is noted that the word determination is not defined in the definition section contained in the Rules. Claim is defined as a claim for loss or damage: A. Under, asserted to be under, or capable of being validly made under, a policy of insurance provided under part 4 of the Motor Vehicles Act 1959 (SA); or B. A Nominal Defendant claim.

13 Conciliation Rule 13.2 provides for conciliation, and Rule provides: if a claimant disagrees with a determination by an approved insurer, and the claimant requests the approved insurer conciliate the dispute, the approved insurer must agree to conciliate the dispute with a conciliator if the claimant s request to conciliate the dispute is made within 30 days of the date of the relevant determination. The term conciliator means a person approved by the Regulator to be a conciliator or if the Regulator has not approved a person or if that person is unavailable, any other person suitably qualified to be a conciliator. Rule provides that the insurer must consider any directions given by the conciliator, obviously meaning that the conciliator s directions are not binding. Interestingly, Rule provides that a claimant who attends a Conciliation Conference is entitled to seek reimbursement from an approved insurer for: Reasonable expenses of the claimant s transport to and from the conciliation up to a maximum of $50.00; Loss of income incurred by the claimant as a result of attending the conciliation up to a maximum of $

14 Declaratory Judgments and Interim Assessments of Damages Further, or in the alternative, to the provisions contained in Rule 13 of the CTP Regulator Rules, a claimant potentially has a right to seek interim relief as follows: Declaratory judgment determining the question of liability; An order for payment of expenses to date of such declaratory judgment for a payment on account of damages and for periodic payments thereafter on account of damages to be assessed and for an adjournment of the final assessment of damages. Section 30B of the Supreme Court Act 1935 (SA) gives the court power to make interim assessment of damages. Section 38 of the District Court Act 1991 (SA) provides for interim awards of damages in that court. The possibility of pursuing an interim assessment of damages is raised simply as a discussion point, noting that such applications have traditionally been pursued in relation to the claims of children with catastrophic injuries.

15 Direct Contact with Claimants Another difficulty which has arisen since privatisation, is the increasing occurrence of direct contact with claimants who are legally represented. Such direct contact often causes difficulty in a solicitor s ability to manage litigation, where the solicitor is not privy to communications which are occurring between the insurer and the claimant. Rule 5.6 sets out the parameters for direct contact between the insurer and the claimant (where the claimant is legally represented). Rule provides:- The approved insurer may send correspondence directly to a claimant who is legally represented if: a) It contains only generic information about making and resolving claims; b) It provides details about AHP examination or other medical examination arranged by the approved insurer; or c) It is in regards to a claimant s rehabilitation; Provided that a copy is also sent to the claimant s solicitor. The above Rule clearly only refers to correspondence, which infers only written communication is permitted.

16 Direct Contact with Claimants - continued I have noted instances where occupational therapists engaged by approved insurers have contacted my clients direct after an Activities of Daily Living Assessment has taken place in order to monitor the progress of their symptoms and treatment (without reference to myself). Furthermore, Rule provides:- An approved insurer may contact a claimant who is legally represented directly if: a) Requested to do so by the claimant; b) There is no substantive reply from the claimant s solicitor to the approved insurer s offer of settlement within 10 days and attempt has been made by the approved insurer to confirm receipt of the offer of settlement; c) There is no substantive reply from the claimant s solicitor to the approved insurer s correspondence (excluding offers of settlement) within 20 days, and an attempt has been made by the approved insurer to confirm receipt of the correspondence; and d) In response to a complaint by the claimant. The above time limits, in my view, can place an unfair obligation on solicitors acting for claimants to respond to trivial requests from insurers to provide wide ranging updates regarding the status of a claim as failure to do so may result in the client being contacted directly.

17 Conclusion Whilst the objective of early intervention is to bring about optimum health outcomes, the experience to date with the privatised scheme suggest that in many instances early intervention objectives are not being met due to various factors which are common in an adversarial setting including: 1. Liability disputes; 2. Causation disputes; 3. Over emphasis upon the obtaining of pre-accident medical records, which in some cases are not directly relevant. As a result of the above, resolution of claims is being delayed, legal costs are rising and simple claims are being made more complex than they need to be. Perhaps the focus upon early intervention as a model has led to unsatisfactory results and some modification is required.