Stephen Wiseman: A doctor’s take on no-fault insurance

By now, everyone has heard of the NDP’s about-face on what it describes as the wonderful new world of ICBC no-fault insurance. Increased benefits and decreased premiums for all, says Premier John Horgan, affirming the change as almost “too good to be true.”

But is it? British Columbians and their doctors already have lots of experience with no-fault insurance through their interactions with WorkSafeBC and some other disability insurers. Let’s hope everyone is happy with this kind of model and service, because ICBC will be offering the same thing as of 2021.

The big picture is that every injured citizen will be dealing directly — without legal advice or support — with a vast bureaucratic apparatus whose interest is split between offering benefits and protecting its bottom line. The government itself says that 700,000 of us don’t even have a regular family doctor in our corner. Any thoughts on how this might turn out?

Take the issue of causation. Say you were injured in a crash but were pushed hard to return to work after six months in spite of ongoing pain. You are not at your best, your boss is unsupportive and critical, and you go off work with symptoms of depression and anxiety. If ICBC decides unilaterally that your symptoms are due to “workplace stress” and not related to your original injuries, you will not qualify for further wage-loss support or psychological treatment. How will you argue otherwise, without a lawyer and quite possibly without a regular doctor?

If you are covered, you will not receive a lump-sum settlement to use as needed, but will be joined at the hip to the ICBC bureaucracy, possibly forever. In the language of no-fault Manitoba Public Insurance, “income replacement will continue for as long as the claimant meets eligibility criteria.” So, every few months, or year or two, you may need to submit burdensome medical proof of ongoing impairment to continue with your wage-loss benefits. Also, at any time ICBC may decide that you could do job X, even part-time, instead of your own job — in the Manitoba plan, this is called “determined employment” — and, of course, if you don’t pursue it, your benefits can be docked accordingly.

About that impressive-sounding new $1,200 per week maximum wage loss benefit? Remember, ICBC must first accept that you cannot work, and they may disagree with you and your doctor about this. Most concerning is that this will be awarded solely based on your current income. If you are doing well in an apprenticeship and stand to finish and make a lot more money, for example, you will not be compensated for those future earnings if you cannot continue with your career.

Then there is treatment. It may be offered, but only continued if ICBC deems you to be objectively improving in your functioning. As with WorkSafeBC, it is irrelevant that, say, massage therapy reduces your suffering and so is important to you. You must essentially prove that it actually makes you function better. And, of course, every condition has a predetermined number of treatments that will be supported, and no more. With the current lump-sum settlement system, if you decide you want the treatment, you can afford it and are not answerable to anybody.

WorkSafeBC also keeps a list of medicines it deems appropriate for any condition, based on its own take on the scientific literature. It decides what is “evidence based” and this trumps your own experience of the treatment almost every time. So, it does not cover opioid painkillers, for example, even at low and stable doses, even if both you and your doctor agree they are helping.

And if you want me to treat your post-traumatic fibromyalgia with slightly more novel approaches such as low-dose naltrexone or transcranial magnetic stimulation, we are both out of luck. Sorry, not enough evidence, in their opinion. The new ICBC model will likely follow this approach to a T.

Finally, there is the issue of access. If ICBC decides you need to see a specialist, will they like the current MSP wait lists? Further enhanced payments to physicians for expedited consultations and treatment will be put in place almost certainly. For those on non-ICBC wait lists, you will go further to the back of the bus, and it will remain illegal for you to pay to expedite your own care.

In my practice, I treat many patients with chronic pain and psychiatric complications caused by car crashes. While the stress of litigation under the current system is often severe and intrusive, it typically comes to an end with a settlement or a court award. While this does not cure any symptom, it does provide many with a degree of closure and relative peace of mind to move on with their lives as best they can.

My patients under prolonged WorkSafeBC and some other disability insurance claims, however, are not afforded such relief. The ongoing interactions with bureaucracy, the paperwork, the treatment rejections, the appeals, the demands to return to work — all can feature in these patients’ lives, and in certain cases have driven some to contemplate and even attempt suicide.

Every approach to car insurance surely has benefits and drawbacks. But don’t let David Eby convince you that he has suddenly cooked up a miracle. We all know about no-fault insurance already. Talk to your family and friends, and to your doctor, about their experiences with the approach ICBC is now adopting.

And be careful of politicians offering shiny new objects. They may not be so good for your health.

Stephen Wiseman is a Vancouver psychiatrist with a special interest in pain.

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