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injury assessments

Stacey Taylor’s hip, shown in this x-ray from a previous story, was damaged in a car accident, leaving her in a wheelchair for months. A doctor assessing her claim for her insurance company concluded that her injuries did not warrant long-term benefits.The Globe and Mail

The Ontario government is moving to set up "independent" assessment centres where medical professionals will examine accident victims with significant injuries in order to advise insurance companies on what treatment and support they need. It also said it will no longer allow doctors' reports to be ghostwritten.

This comes after a Globe and Mail investigation revealed some injury-assessment firms and doctors were creating medical reports, paid for by insurance companies, that were found to be inaccurate, unfairly biased against accident victims or even written by staff at the assessment firms.

Licensed to bill: How doctors profit from injury assessments that benefit insurers

Insurance assessment firms altered, ghostwrote accident victim reports

"Recent news reports show that some bad actors, including insurers, lawyers and medical clinics, are taking advantage of people and the system at the expense of victims," said Ontario Finance Minister Charles Sousa.

"We need it to be neutral, we need it to be independent, we need it to be credible. We need it to be held to a high standard."

Under the current system, both insurance companies and injury lawyers hire different doctors and assessment firms to evaluate accident victims, creating a drawn-out, expensive scenario known as "duelling assessments." Hundreds of Canadian doctors are highly paid to do this work, full time or on the side.

Legitimate accident victims with significant injuries told The Globe they pay the highest price, enduring the stress and strain of numerous assessments, while their fight for coverage drags on for months or years. A key problem, as they see it, is the doctors working the insurance side are beholden to whoever is paying them, because the accident victims are not their patients.

Mr. Sousa is promising that will soon change.

"There won't be any conflict because [the medical professionals] won't be subject or held accountable to an insurance company or legal profession," he said.

The government announcement was short on key details, though. Mr. Sousa didn't spell out who will run the centres, just that they will be "subject to a bidding process." Asked if the doctors will continue to be paid by insurers, he said that "insurance-company obligations are to pay for legitimate assessments." His office later confirmed the industry will foot the bill.

"If insurers are writing out the cheques, that's still a problem," said Rhona DesRoches of FAIR, a group that advocates for accident victims.

Ms. DesRoches suggests insurers should instead be made to rely on the opinions of the accident victims' own doctors and whomever those doctors refer them to, with limits on the number of assessments. Insurers could then be made to reimburse medical professionals for their reports.

"Your treating physician has a vested interest in your health-care outcome and generally any help you do get comes from that direction," she said.

The Ontario Trial Lawyers Association wants to know how the government will ensure physicians working at the new centres aren't the same doctors that judges and arbitrators have found to be biased or not credible.

"Who makes the decision as to which assessors are highly credible, and what standards are being used?" president Claire Wilkinson asked.

The Insurance Bureau of Canada said it welcomes the move to the new "independent" centres.

"The auto-insurance industry is very much against the 'duelling assessments' system," spokesman Andrew McGrath said. "It is very expensive, time-consuming and undermines public confidence."

The Globe has heard from several physicians across Canada who are also highly critical of how the current practices affect their patients.

Toronto practitioner Howard Goldstein said he thinks the College of Physicians and Surgeons should be doing much more to weed out what the Finance Minister referred to as the "bad actors."

"The CPSO had failed to act in a responsible way when dealing with such cases and the physicians who knowingly take advantage of a system that is acutely remunerative," Dr. Goldstein said.

"Although charged with the responsibility of protecting the public and regulating the profession, they are more interested in sanctioning outspoken physicians than those who would transgress their ethics and professionalism."

Hamilton physician Michael Pray said he believes the college can't do much on its own, however, because in his opinion the government allows the insurance industry to call most of the shots.

"The rules being skewed in favour of insurance-company profits versus actually helping patients get better after a motor-vehicle accident have led to this bizarre situation," Dr. Pray said. "We spend a great deal of time trying to right the wrongs inflicted on our patients."

The government also announced other changes to the auto-insurance regime, including "standard" treatment plans for minor injuries, no more cash payouts for victims without invoices and a beefed-up system for fraud detection and prosecution.

The Finance Minister said his overall goal is to reduce auto-insurance premiums in Ontario, which are the highest in Canada.

Kathy Tomlinson is an investigative reporter in The Globe and Mail's Vancouver bureau.