Caution Against Insurer Examination Physician Upheld By Appeals Board

The Health Professions Appeal and Review Board has confirmed the decision of the Inquiries, Complaints and Reports Committee of the College of Physicians and Surgeons of Ontario (CPSO) to issue a caution to an occupational medicine physician regarding her inadequate and inaccurate report.

The physician has not been named as it is the policy of the health regulatory Colleges to only named disciplined regulated health professionals not those cautioned.   In fact, I could not find an anonymized report of doctors who have been cautioned on the CPSO website.  However, as reported yesterday, the Ministry of Health intends to change that policy and increase transparency by allowing the Colleges to name professionals who have been cautioned.

In this particular case, the an auto insurance claimant was injured in a motor vehicle collision on November 1, 2010. The insurer, State Farm, sent the claimant to the occupational medicine physician (Dr. K.I.) for an insurer examination under s. 42 of the SABS. The assessment was a paper review to determine whether the claimant required further psychological assessment as a result of the accident.

The claimant complained to the CPSO that the physician failed to provide an accurate opinion of her claim for psychological services to her insurer.  The CPSO's Inquiries, Complaints and Reports Committee determined that occupational medicine physicians do perform psychological impact assessments and that the Dr. K.I. had the qualifications required to make a determination as to whether the claimant was eligible for a psychological assessment.  Dr. K.I. showed that she was trained in psychiatry and psychiatric/psychological issues and that assessments are a regular part of her practice.

However, the Committee noted that Dr. K.I.’s report contained inaccuracies with respect to the details of what happened at the time of the collision. The report omitted the fact that the police were called, the car was damaged to the extent that it had to be towed away and was written off, which the Committee wrote, “speaks to the extent of the motor vehicle accident”.    Further, the Committee found that the physician failed to address important information that supported a claim for psychological services such the fact that the claimant's family physician felt that a referral for psychological services was indicated and a number of psychological test results.

While the primary focus of the complaint to the Appeals Board was whether a psychologist rather than a physician should have conducted the assessment, the Board did not find the complaint limited to this issue.

The Board also reviewed the concern that Dr. K.I. had “failed to provide an accurate opinion of [the claimant’s] claim for psychological services to the insurer." The Board considered that the accuracy of the opinion to be the central issue and the appropriate expertise was an example of the concern.

The Board agreed with the Committee that the report was both inaccurate and inadequate and failed to comply with the College policy, “Third Party Reports,” which notes that when providing a third party report physicians must "take reasonable steps to ensure that they have obtained and reviewed all available clinical notes, records and opinions relating to the patient or examinee that could impact the findings of the report ...” Moreover, the policy also states that physicians “should ensure to the best of their abilities that the information contained in the third party report is accurate.”

So what can we learn from this case?

1. Physicians can be used to evaluate requests for psychological services if they have appropriate training and experience.
2. IE providers need to consider all available clinical notes, records and opinions relating to the claimant.  If they have not, the report can be challenged and the provider could be subject to sanction from their College. 
3. The lack of transparency in these cases does not adequately protect consumers and insurers from inadequate assessors.
4. There is a need to implement the Automobile Insurance Anti-Fraud Task Force recommendation regarding the development of professional standards, guidelines and best practices to improve the quality of independent medical assessments.