Medical Evaluations: Whom Do They Really Benefit?

Car accident victims in Ontario may find that the province's insurance system almost seems to punish them for making a claim! This observation was made by FAIR (For Accident Insurance Reform) the organization that supports accident victims through advocacy and education.

Such organizations help to advocate the cause of insurance industry reforms. Another important area is to ensure that equitable funding is allocated to all the parties involved – claimants, insurers, health-care providers and the legal representatives.

A landmark case in this issue was Macdonald vs Sun Life Assurance Company of Canada, 2006. During the course of testimony, it was revealed that a doctor's medical report was rewritten by a company that had retained the doctor to conduct the defense's medical evaluation. The case is now used as a yardstick for arguments against Ontario's accident benefits and auto insurance systems.

What Are Independent Medical Evaluations?

When an injured person makes a claim for medical benefits, the insurance company can counter it with an Independent Medical Evaluation (IME). It is a well-known fact that most insurance companies have a pool of IME physicians whom they regularly use for this purpose. Such doctors routinely conduct hundreds of such IMEs annually and they form a significant part of their practice and income.

To qualify for no-fault or statutory benefits in Ontario, certain conditions have to be met. Terms like “accident” are defined under the law. The evaluation and the opinion of the evaluating physician are used to settle claims and the value of claims. The reports provided in the IME can influence or determine whether the insurer will pay for recommended treatment and whether the injured person will be compensated for the injuries.

The Question of Bias

Toronto lawyer, Loretta Merritt opines that procuring a genuinely impartial medical evaluation has become a “costly and complicated endeavor and assessment clinics are part of the problem.”

One of the issues faced by accident victims is that they have no way of knowing the history of the doctor conducting the IME. This particular doctor may have a record of complaints but such a history is kept legally confidential by the College of Physicians and Surgeons of Ontario. Unless there is a formal finding of misconduct against the doctor, his/her records remain inaccessible to injured victims and their legal representatives.

Doctors cannot also be confronted by past judicial findings about their conduct or conclusions in other cases. Such information is kept secret from judges/jury/arbitrators in other cases where the doctor conducts IMEs.

This lack of transparency and true independence on the part of IME physicians can seriously affect the conclusions in an ongoing case. Reports are “rewritten” by clinics attempting to toe the insurer's line. FAIR has evidence of victims being sent for up to 40 IMEs, of victims seeking a mere $5000 compensation and insurers spending $10,000 in IMEs that declare that it need not be awarded!

If you or a dear one has been injured in an automobile accident, consult an experienced personal injury lawyer. We can ensure that your rights and interests are protected and safeguarded.