Ontarians injured in car accidents are finding out that in many cases, the rehab prescribed by their health providers will not be covered by their insurance.
Dr. Donna Ouchterlony, the director of the brain injury clinic at Toronto's St Michael's Hospital, says insurance companies are declining more and more treatment plans.
"They no longer have to have a doctor review [in order] to refuse [treatment]," she said. "The impact is profound."
"An insurance adjuster with very little training can refuse the treatment plan of a specialized team. They apparently have to have a medical reason, but they're not a doctor, they're not even a nurse ... they don't have any medical training," she said.
Some suggest that as many as 40 per cent of claims are being turned down.
In September 2010 the Ontario government introduced new auto insurance regulations in an attempt to put an end to fraud and rising premiums — fraud costs alone are estimated at more than $1 billion per year.
For what is deemed a catastrophic injury, the level of coverage remains at $1 million.
But benefits for non-catastrophic injuries were cut in half to $50,000. Benefits for minor injuries were capped at $3,500.
Andrew Ryan is one of the people who had the treatment recommended by his health-care provider rejected.
Ryan was cycling toward his home in Toronto's east-end two summers ago when a car ran a red light and smashed into him.
"My bike collapsed under me, sending me head-first into the ground," he recalled.
His head injury stopped him from working as a web designer and it affected his speech.
But his car insurance company rejected the speech and occupational therapies recommended by his health-care providers.
Dr. Ouchterlony said most patients can go through benefits very quickly.
But the Insurance Bureau of Canada, which represents the insurance companies, says too many therapists are recommending unnecessary treatments.
"I do have a difficult time accepting a blanket statement — a broad generalization — that a lot, that most [therapy recommendations] are being declined," said IBC spokesman Ralph Palumbo.
"There are too many of them frankly that are putting in claims that should never see the light of day," he said.
Fast-rising fraud costs
Insurance companies point to the fraudulent claims that eat up Ontario drivers' premiums every year — a statistic backed up by Ontario's auditor general in a recent report, which sets the fraud figure at $1.3 billion.
That report also said Ontarians pay the highest auto insurance premiums in the country in part because the average cost of accident injury claims is five times higher than other jurisdictions.
Palumbo says anyone injured in an auto accident should be confident they will be cared for.
"Where there are legitimate claims, absolutely they should be approved and the person should get treatment. But there's too much of the other, which is, people trying to milk the system. I can't say it any blunter than that."
But Dr. Ouchterlony says the provincial government needs to make changes to the program. "[T]hey don't understand what they're doing — the predicament that they're putting patients in is absolutely horrible, and it must be that they don't understand what's going on," she said.
"I want to see the government restore the program the way it was."