Motor vehicle accident insurers could use independent medical advice

Independent Medical Advice for the Motor Vehicle Accident Insurer

Nov 20, 2018

How do you figure out what a Motor Vehicle Accident insurance claimant is entitled to?

When a Motor Vehicle Accident claimant seeks benefits from their insurer, there’s much to bear in mind. Your job is discovering if the claimant’s injuries qualify for payments. But that’s often not an easy choice. Especially when you consider what they might be looking for — and the situation they’re in. 

  • Income Replacement, for lost income due to inability to work
  • Non-earner, for when the injury makes the claimant unable to continue a normal life
  • Caregiver, to compensate for expenses when they can’t continue as a main caregiver
  • Medical, for injury-related medical expenses
  • Rehabilitation, for when the injured requires it
  • Attendant Care, to offset the cost of an attendant
  • Compensation for Other Expenses, depending on what your policies may cover

The stress of an auto accident can take its toll on a person, and understandably they’ll be seeking the benefits they’re entitled to. You need to wade through their claims and find out if they’re appropriate. Do they qualify for some, but not other benefits? Do they fail to qualify at all — or does it depend on the extent of the injury or the projected recovery period?

The Red Flags in MVA Insurance

There’s so much that can go into any of these benefit claims. With Income Replacement, are they completely unable to do their existing job? Are they able to do parts of it with employer accommodation? Is it likely that the claimant is able to return to work within a few weeks, months, years — or will they never return at all? Most importantly: how can you tell?

Depending on the claimant’s policy, they may also have to prove that not only can they do their own job, but that they’re not able to do any job that their qualifications and experience allow for. Likewise, if they require benefits because they’re not able to fulfil their duties as a caregiver, is it really the case that they can’t perform? Is rehabilitation treatment actually necessary, or are their injuries probably going to heal themselves?

Then, how complete does the medical documentation sound? A seemingly incomplete picture could point to a problem you need to take notice of. If it involves work or the inability to do something else, you’ll need to consider when they stopped doing it, or if you have any reason to believe they still are. Did the injury clearly become apparent at the accident, such as a broken leg — or did it take some time to develop? Does the timing align?

When a claimant’s complaint falls into the area of somatoform disorder, it may require further investigation. These issues, such as myofascial pain syndrome, cannot be objectively verified, even when the claimant could be feeling real pain.

The MVA insurer will also need to take particular care with chronic whiplash cases. You don’t have to take them at face value. There’s also the greater issue of medicalization, where non-medical issues are falsely elevated to status of medical problem. Even when accompanied with documentation from a GP, you do have options.

Dig Deeper and Obtain Clarity with Independent Medical Advice

An Independent Medical Examination involves retaining an independent medical expert to examine a claimant. They will use their knowledge and expertise to provide an opinion about the condition in question. You’ll then receive an authoritative report that you can use to aid your decision-making in case management.

Insurance policies are complicated. Injuries and illnesses can also be complicated. Relying on just the information that you’re given by the claimant and their doctor might not be enough for you to see that a claim satisfies the minutia of the policy in order to trigger a payment.

You’ll get access to an expert with specific expertise in the area of medicine in question. This seasoned opinion will usually carry more weight and paint a fuller picture than the patient’s general practitioner and will help you come to a decision that you can not only be confident is the right one, but that you can more easily defend, should the case escalate.

Looking to get started? We have a page just for MVA insurers right here that compiles all this and more into one handy information resource.

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