statutory accident benefits schedule (sabs) & wsib ... · mva before june 1, 2016...
TRANSCRIPT
Statutory Accident Benefits Schedule (SABS) & WSIB Programs of Care
Dennis Polygenis B.Sc. PT., MCPA
Practical Application of the Statutory Accident Benefits Schedule (SABS)
Medical and Rehabilitation Benefits
MVA before June 1, 2016
Minor Injury (MIG) – maximum $3,500 over 12 weeks (OCF-23)
Non-catastrophic – maximum of $50,000 (OCF-18)
Catastrophic – maximum $1,000,000
MVA after June 1, 2016*
Minor Injury (MIG) – maximum $3,500 over 12 weeks (OCF-23)
Non-catastrophic – maximum of $65,000 in combination with attendant care
Catastrophic – maximum of $1,000,000
* Opt-in coverage may be higher
SABS Benefits Summary
Benefit Pre-2016 SABS Post-2016 SABS
Medical and Rehabilitation for non-catastrophic injuries
$50,000
Benefits have been combined and reduced to $65,000 total
Attendant Care for non-catastrophic injuries
$36,000
Medical and Rehabilitation for catastrophic injuries
$1,000,000 Benefits have been combined and
reduced to $1,000,000 total
https://www.fsco.gov.on.ca/en/auto/brochures/pages/brochure_changes10.aspx
SABS Optional Benefits Summary
Pre-2016 SABS Post-2016 SABS
Non-catastrophic injuries
Medical and Rehabilitation for non-catastrophic injuries $100,000
$72,000 and $100,000 options have been eliminated.
New: Combined Medical, Rehabilitation and Attendant Care of $130,000** for non-catastrophic injuries.
Attendant Care for non-catastrophic injuries $72,000
Catastrophic injuries
Not available New: Combined Medical, Rehabilitation and Attendant Care of
$1,000,000 for catastrophic injuries only.
*$130,000 optional combined (non-catastrophic injuries) and $1 million optional (all injuries) cannot be purchased together. ** Duration of benefit is five (5) years for adults.
https://www.fsco.gov.on.ca/en/auto/brochures/pages/brochure_changes10.aspx
Housekeeping & Home Maintenance
MVA before June 1, 2016
Non-catastrophic – maximum of $3,000 per month and $36,000 for up to 2 years after accident
Catastrophic – maximum of $6,000 per month and $1,000,000
MVA after June 1, 2016
Non-catastrophic – maximum of $3,000 per month and $65,000 (including Med/Rehab benefits) for up to 260 weeks
Catastrophic – maximum of $6,000 per month and $1,000,000
Attendant Care Benefits
Prior to June 2016:
Non-catastrophic – $50,000
Catastrophic - $1,000,000
Post June 2016:
Non-catastrophic MIG – 0
Non-catastrophic Outside MIG -$65,000 in
combination with MR benefits
Catastrophic - $1,000,000 in combination with MR
benefits (unless option purchased)
SABS – Duration of Benefits
20. (1) Subject to subsection (2), no medical, rehabilitation and attendant care benefit is payable for expenses incurred,
(a) more than 260 weeks after the accident, in the case of an insured person who was at least 18 years of age at the time of the accident; or
(b) after the insured person’s 28th birthday, in the case of an insured person who was under 18 years of age at the time of the accident. O. Reg. 251/15, s. 10.
(2) The time limits set out in subsection (1) do not apply in respect of an insured person,
(a) who sustains a catastrophic impairment as a result of the accident; or
(b) who is entitled to optional medical, rehabilitation and attendant care benefits under paragraph 4 of subsection 28 (1) or catastrophic impairments benefits under paragraph 5 of subsection 28 (1). O. Reg. 251/15, s. 10.
Income Replacement Benefits
• After first week, paid at 70% of gross pre-Accident income
(reduced by collateral benefits available or received) to
maximum of $400 per week (reduced by 70% of post-Accident
earned income).
• Continued payment after 104 weeks is subject to a more
stringent “any occupation” test and payable at a minimum of
$185 per week. Benefits reduce by formula at age 65 (subject
to a 2 year minimum).
Non-Earner Benefits
MVA after September 1, 2010
MVA after June 1, 2016
Payable after 26 weeks at $185 per week if completely unable to carry on a normal life. Increases
to $320 per week from 104 weeks after accident if a student within the 52 weeks prior to the
accident. Benefits reduced by formula at age 65 (subject to 2 year minimum). Payable after age 16
and for life.
Payable after 4 weeks at $185 per week if completely unable to carry on a normal life. Payable after
age 18 and for maximum of 104 weeks.
Caregiver Benefits
Non-Catastrophic – Not Available
Catastrophic – Payable, without waiting period, if substantially unable to
continue caregiving activities, at maximum of $250 per week for first person,
plus $50 for each additional person in need of care. Changes at 104 weeks
to a more stringent “complete inability” test. Terminates once children attain
age 16 or no longer a person in need of care. No adjustment at age 65.
Minor Injury Guideline (MIG)
The MIG - Objectives
The objectives of this Guideline are to:
a) Speed access to rehabilitation for persons who sustain minor injuries in auto accidents
b) Improve utilization of health care resources
c) Provide certainty around cost and payment for insurers and regulated health professionals and
d) Be more inclusive in providing immediate access to treatment without insurer approval for those persons with minor injuries as defined in the SABS and set out in Part 2 of this Guideline.
https://www.fsco.gov.on.ca/en/auto/autobulletins/2014/Documents/a-01-14-1.pdf
The MIG
This Guideline is focused on the application of a functional restoration approach, in addition to the provision of interventions to reduce or manage pain or disability
The SABS and this Guideline are intended to encourage and promote the broadest use of this Guideline, recognizing that most persons injured in car accidents in Ontario sustain minor injuries for which the goods and services provided under this Guideline are appropriate.
Usage of the Guideline by all stakeholders will be monitored on an ongoing basis, with a view to early identification and response to inappropriate application or interpretation of the SABS and the Guideline.
This Guideline is focused on the application of a functional restoration approach in the management of minor injuries in the acute and sub-acute phases of the injury.
The MIG
3. Impairments that come within this Guideline
Subject to the exception in Section 4 below, an insured person’s impairment comes within this Guideline if the impairment is predominantly a minor injury.
Minor Injury Guideline
Non-minor Injuries
An insured person’s impairment does not come within this Guideline if the insured person’s impairment is predominantly a minor injury but, based on compelling evidence provided by his or her health practitioner, the insured person has a pre-existing medical condition that was documented by a health practitioner before the accident and that will prevent the insured person from achieving maximal recovery from the minor injury if he or she is subject to the $3,500 limit referred to in section 18(1) of the SABS or is limited to the goods and services authorized under this Guideline.
Non-minor Injuries
Psychological injuries
Concussion/TBI
TMJ dysfunction
•Intracapsular disc is cartilage not a ligament or tendon
WAD III injuries
•Neurological symptoms
•MRI as a screening device
Identify disc herniations/bulges
•Fractures/dislocations
Non-minor Injuries
Chronic pain •May start as WAD II
•Psychological component
•Pre-existing condition
Minor injury primary factor contributing to the impairment
Arruda and Western Assurance • Arbitrator Jeffrey Shapiro concluded that a diagnosis of chronic pain
syndrome can remove an injured accident victim from the Minor Injury Guideline.
• The insurer did not discharge its “…ongoing duty to assess and reassess a claim as new information is available…” by ignoring the new evidence in this case when presented with it.
The MIG – Pre-Existing Conditions
The existence of any pre-existing condition will not automatically exclude a
person’s impairment from this Guideline. It is intended and expected that
the vast majority of pre-existing conditions will not do so.
Only in extremely limited instances, where compelling evidence provided by
a health practitioner satisfactorily demonstrates that a pre-existing
condition that was documented by a health practitioner before the
accident, and that will prevent a person from achieving maximal recovery
from the minor injury for the reasons described above, is the person’s
impairment to be determined not to come within this Guideline. Exclusion
of a person from this Guideline based on reasons or evidence falling short of
this requirement is inconsistent with the intent of the SABS and this
Guideline.
The MIG – Supplementary Good and Services
8. d) Supplementary goods and services during the treatment phase
Additional funds are available to provide supplementary goods and additional services to support restoration of functioning and address barriers to recovery. The supplementary goods and services may include but are not limited to:
Treatment services for the additional minor injuries arising from the same accident.
Goods required for self-directed exercise and/or pain management such as, but not limited to: theraband; gym ball; hot/cold packs; back support; lumbar roll; etc.
Assistive devices required to maintain/return to work/school/home or personal activity such as but not limited to: head set; trolley; braces.
Supportive interventions such as advice/education to deal with accident-related psycho-social issues, such as but not limited to: distress; difficulties coping with the effects of his/her injury; driving problem/stress.
The health practitioner, a regulated health professional or an appropriate health care provider may provide the supplementary goods and/or services that are deemed necessary, up to a maximum cost of $400.00, without approval of the insurer.
MIG Math
Funding Category Funding Allowance
Treatment under the MIG Block 1 (Week 1-4) $775
Block 2 (Week 5-8) $500
Block 3 (Week 9-12) $225
Treatment Total $1,500
Other Initial visit $215
Supplementary goods and services $400
Completion of Minor Injury Discharge Report (OCF-24) $85
Other Total $700
Subtotal under the MIG $2,200
Additional funding under s18(1) of SABS
With an OCF-18
$1,300
Total MIG Funding $3,500
Serious impairment
If injury is ‘minor’ the Plaintiff must prove serious impairment to avoid the cap
•An impairment of a physical or cognitive function that results in a substantial inability to perform (the normal activities of the claimant’s daily living)
Catastrophic Injuries
SUMMARY OF NEW CAT DEFINITION (FOR ACCIDENTS AFTER JUNE 2016)
Current System New 2016 SABS Model
Paraplegia/Tetraplegia As outlined by generalized terms in Criterion 1 Relies on definitions as found in the ASIA Impairment Scale
Ambulatory Mobility As outlined by generalized terms in Criterion 2 Relies on more specific definitions of levels of amputation and on the Spinal Cord Independence Measure, Version III
Traumatic Brain Injuries
1. GCS criteria (<9)
2. GOS criteria
3. “Brain impairment” used
1. GCS Criteria discontinued , direct investigation and
imaging criteria introduced
2. Glasgow Outcome Scale Extended (GOS-E)
implemented
3. Language is now “traumatic brain impairment”
55% WPI criteria – Physical
Impairments Utilizes the AMA Guides 4th Edition Unchanged
Combining of Physical and
Mental Health Impairments
Based on case precedent (Desbien, Kuszniers)
in Ontario around the AMA 4th
Required to apply AMA 6th to obtain mental health
QPI and combine with physical findings from AMA
4th
Key tests include BPRS, GAF and PIRS
Mental Health Impairments
Criterion 8 – requires a class 4 or 5 rating as in
Ch. 14 of AMA 4th (Pastore – only in 1
category)
Revised to require 3 or more impairments at Class 4
level, or 1 at a Class 5 level (AMA 4th)
SABS CAT 2016 CHANGES
SABS CAT DEFINITION
2010-2016
GCS
GOS
Psych WPI approaches (Desbien AMA4 Ch. 4,
California GAF)
M/B Criteria 1x Class4
NEW 2016 SABS CAT DEFINITION
ASIA, GOS-E
SCIM, KOSCHI
AMA6: GAF, BPRS, PIRS
‘Bowel Routine’ ‘Radiological Findings’
THE FSCO PERSPECTIVE
FSCO Superintendent’s Report on the Definition of Catastrophic Impairment in the Statutory Accident Benefits Schedule (December 2011):
“I have also reviewed the Expert Panel’s Phase II Report on the qualifications and experience for catastrophic impairment assessors, designed to standardize and maximize the quality of assessments. I have accepted the Panel’s recommendations in this area, with some modifications.”
Superintendent’s Recommendation (5.3): Evaluators conducting assessments of catastrophic impairments must have formal training in the use of the measurement tools that are directly relevant to their scope of practice.
The Panel recommends that all Evaluators involved in the assessment of catastrophic impairment have formal training in the use of the measurement tools that are directly relevant to their scope of practice. The measurement tools are: ASIA Scale; GOS-E; Spinal Cord Independence Measure; GAF; and the AMA Guides.
The Panel believes that proper training would improve the quality of assessments and standardize the way assessments are conducted. As a result, the system would be less prone to assessor bias and inconsistent use of measurement tools.
I accept the Expert Panel’s recommendation.
Superintendent’s Recommendation (5.4):
While I believe the university-based training advocated by the Panel would be an asset, I am not recommending this as a requirement to qualify as an Evaluator. I do however recommend that Evaluators who frequently conduct catastrophic impairment assessments should obtain this further education and thereby strengthen their knowledge and skills.
Superintendent’s Recommendation (5.6):
…. Phase II – One year after the new definition takes effect, all Evaluators must have completed training in the use of measurement tools described in the SABS definition of catastrophic impairment that are relevant to their scope of practice.
SABS FORMS
Application for Accident Benefits (OCF-1)
Completed by claimant when applying for any benefits under the SABS
Basic accident details
Dependents
Employment status
Must be returned in 30 days
Employer’s Confirmation of Income (OCF-2)
Completed by employer when claimant is applying for Income Replacement Benefits (IRB)
Includes hours of work, salary and basic job description
This information is used when scheduling JSA’s
Disability Certificate (OCF-3)
Completed by one of the claimant’s healthcare professionals (chiropractor, dentist, occupational therapist, nurse practitioner, optometrist, physician, physiotherapist, occupational therapist, speech language pathologist or psychologist).
Accident related impairments (ICD-10 CODES)
Pre-accident history
Ability to return to work
Ability to perform housekeeping and home maintenance functions
Caregiver
Attendant Care
Non-earner
***This document is used by adjusters to determine insurer assessments and applicable benefits under the SABS.***
Permission to Disclose Health Information (OCF-5)
Consent from the claimant for the insurer to collect health information from the health practitioner.
Treatment & Assessment Plan (OCF-18)
Application for treatment and assessment services outside of the Minor Injury Guideline.
Application for treatment and assessment services when the goods and services provided under the MIG are utilized.
Must be submitted via HCAI
Fees should follow Professional Services Guidelines (SABS)
Treatment Confirmation Form (OCF-23) MIG
Application for Determination of Catastrophic Impairment (OCF-19)
Form 1: Assessment of Attendant Care Needs
• Normally completed by an occupational therapist or nurse
Level 1: Routine personal care
Level 2: basic supervisory functions
Level 3: complex health/care and hygiene functions
WSIB TREATMENT PATHWAYS
WSIB Programs of Care (POC)
Currently there are 4 programs of care
Musculoskeletal
Shoulder
Low back
Mild Traumatic Brain Injury (MTBI)
Musculoskeletal POC
8 weeks in duration – minimum 6 visits
$500 – if worker able to RTW
$600 – if worker unable to RTW
An allowed WSIB claim, within 8 weeks from the date of injury or recurrence
No clinical evidence of red flags and no evidence of orange or yellow flags that are a barrier to participation in this active rehabilitation program
A diagnosis of one injury or more to a muscle, tendon, ligament, fascia, intra-articular structure or any combination of these structures, causing mild to moderate tissue damage (Grade I or II)
MSK POC Exclusions
tears and ruptures (Grade III) that may require surgical repair
Fractures
Any condition that would preclude a worker from participating in an active rehabilitation program.
Shoulder POC
8 weeks in duration – minimum 7 visits
$560
An allowed shoulder claim by the WSIB within 16 weeks from date of injury
No clinical evidence of significant red or yellow flags
A diagnosis of bursitis, bruises/contusions, impingement syndrome, rotator cuff tendinitis, sprains/strains or partial tear(s) of the rotator cuff or other structures.
Shoulder POC Exclusions
Adhesive Capsulitis (Frozen Shoulder)
Brachial Plexus Injuries
Complete Rotator Cuff Tears
Dislocations
Fractures.
Low Back POC
8 weeks – Two Phases
$770 if completes all phases
With an acute low back injury (up to 6 weeks from date of injury/recurrence)
Who may also have another injury that does not preclude the worker from participating in this Program of Care
Assessed within the first 42 days from date of injury and/or recurrence
With no clinical evidence of significant red or yellow flags
Still at work (regular or modified) or off work
Not hospitalized.
MTBI POC
2 Treatment Blocks
Block 1 – Education Stream (Week 1-2) - $200 (min. 2 visits)
Block 2 – Active Treatment
Cognitive Rehab (up to 24 weeks) - $330 (minimum 6 visits)
Manual Mobilization (up to 24 weeks) - $240 (minimum 5 visits)
Diagnosed with a workplace MTBI by a physician
Approved claim for MTBI with the WSIB
Within one year post date of injury
Not hospitalized.
MTBI Exclusions
moderate or severe brain injury
other injuries being treated through the WSIB Serious Injury Program
cancer of the central nervous system
structural defect of cranial vault at the time of injury
penetrating brain injury
a psychiatric disorder/psychopathology such that the MTBI POC would interfere with the treatment of this condition
physical impairments or concurrent injuries that would prevent the worker from being assessed and/or treated in the MTBI POC.