Ontario Brain Injury Association

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1 Ontario Brain Injury Association Sivan Raz Senior Policy Analyst Auto Insurance Policy Unit Financial Services Commission of Ontario 5160 Yonge Street Box 85 Toronto ON M2N 6L9 Dear Ms. Raz, On behalf of the Board of Directors of the Ontario Brain Injury Association, I thank you for the opportunity to make a submission for input on the Catastrophic Impairment Report I Consultation. The Ontario Brain Injury Association (OBIA), is a registered charity that has been working to enhance the lives on Ontarians living with the effects of acquired brain injury through education, awareness and support since We offer no hard rehabilitation services to people with acquired brain injury, so we cannot benefit or be hurt by changes to auto insurance in Ontario. Our main priority is to advocate on behalf of people with brain injuries to ensure that they receive the reasonable and necessary services that they are entitled to in order for them to achieve the best quality of life possible given their circumstances. As part of our support to Ontarians who have experienced brain injury, we offer a toll-free helpline that takes about calls per month from both survivors of brain injury and their family members. Many of these calls are from and about people who have been injured in motor vehicle collisions. As a result we have an abundance of opportunities to hear the consumer s perspectives on and experiences with auto insurance. Furthermore, we receive calls from family members who s loved ones have never been diagnosed with a brain injury and yet have severe neurological impairments and functioning after a motor vehicle collision. One of the services we provide is helping them navigate through the necessary steps to access the appropriate assessments needed to determine if they have a brain injury. These calls come to us months and even years after their motor vehicle collision. Therefore, given OBIA s mandate, services and compilation of membership which includes brain injury survivors, caregivers and their families we are in a unique position to comment on changes to the definition of catastrophic impairment (CAT). Please find our concerns outlined attached. Sincerely, Ruth Wilcock Executive Director

2 Page 2 Ontario Brain Injury Association Concerns about the Changes to the Definition of Catastrophic Impairment Preamble: The Chair of the Panel reserved the right to seek opinions from individuals outside of the Panel to inform the work of the Panel. The Ontario Brain Injury Association (OBIA) was not consulted by the Panel who are making the recommendations for change. OBIA has several concerns about the recommended changes. These concerns are outlined below. 1. Changes are Premature The Report to the Superintendent dated April 8, 2011 is a work in progress. The Panel expressed that there are still challenges to be resolved and have made recommendations on how to address these challenges. Those recommendations include convening an Expert Panel to look at combining physical and psychological impairments and an Expert Panel to look at rating the Paediatric population. The Panel also recommended an intra-examiner to look at the issue of classifying traumatic brain injury in children. Lastly, the Panel recommended criteria to address the issues of premorbid vulnerability from illness or ageing. For all of these reasons it is our contention that it is premature to proceed with any of the recommendations made in the Report at this time. 2. Make-Up of the Panel It is noted that three out of the eight members of the panel have been consultants for the Insurance Bureau of Canada. At the Catastrophic Impairment Project Information Session on April 28 th, Mr. Willie Handler responded to the issue of the conflict of interest by panel members by stating we did not look at who people worked for but rather on their experience. Since the panel argues for changes based on evidence which encompasses investigating and taking into account all aspects why was this principle not applied to the screening and choosing of candidates for the expert panel? It is our contention that all medical experts on the panel should be clearly unbiased on such an important issue. 3. Proposed Changes to the Definition of Traumatic Brain Injury in Adults The requirement that the brain injury survivor be accepted for admission to a program of inpatient neurological rehabilitation at a recognized neurological rehabilitation centre is particularly flawed. OBIA has members who have never spent a day in an inpatient

3 Page 3 rehabilitation facility but have severe brain injuries that meet the definition of CAT. In our current system we know that people are falling through the cracks, under the proposed change this will become and even wider crevice. Some of the proposed changes are ambiguous and create the following concerns: a) The existing recognized neurological rehabilitation centres have specific criteria for admission. What happens if a brain injury survivor does not meet the centres criteria? What happens if a brain injury survivor cannot be assessed in a timely manner? Will these centers be admitting people on paper pending physical admission down the road? The proposed changed will only increase the already long waiting times for treatment and an already stressed system. b) The definition fails to address when the brain injury survivor needs to be admitted. Can it be any time after the injury? What if it s 18 months postinjury? c) If a person with a brain injury is accepted into an inpatient rehabilitation program, and receives an interim catastrophic designation but is on a long waiting list, can this person receive rehabilitation services outside of the parameter of an inpatient rehabilitation facility? d) The lack of recognized neurological rehabilitation centers creates regional disparity. Rural brain injury survivors are at a disadvantage under this definition. Many families want to help their injured family members heal at home. Scientific studies show that the support or family and friends have a positive effect on recovery after a brain injury. Asking survivors of brain injury to leave their support network to attend a rehabilitation center is not always the best option. Further, there are a significant number of family members who would not send a loved one out of town to a rehabilitation facility without sending another family member for support and care. For working families, this would mean taking time off work and major disruption to the family unit. This would further increase the amount of caregiver burn out already being reported. Additionally, this case scenario may put further financial strain upon the family and other financial systems such as Employment Insurance. e) After a trauma, families are not necessarily in the best position to consider the ramifications of taking a family member home vs. admission to a neurological rehabilitation centre. Under the proposed changes, the decision to take a loved

4 Page 4 one home would exclude the survivor of brain injury from receiving services that may be available in their community. f) The requirement for admission to a neurological inpatient rehabilitation centre puts the onus on front line medical personnel (ER doctors, family doctors etc.) to not only recognize and diagnose a brain injury but to facilitate admission to a facility. In OBIA s experience, brain injuries are often missed right after a trauma, especially if there are other injuries that need attending to. In addition, it is often at the point when the brain injury survivor attempt to return to their normal lives when the true deficits are realized. The deficits may include things such as memory loss, inability to organize, sequence and lack of physical and mental stamina. Again, these people under the proposed changes would fall through the cracks. g) The proposed definition completely leaves out the numerous brain injury survivors who seek assistance through community based rehabilitation programs. These programs are just as effective and are more cost effective. Under the proposed definition, these brain injury survivors would be left out. h) The introduction of the Extended Glasgow Outcome Scale (GOS-E), the American Spinal Injury Association (ASIA) criteria and the Global Assessment of Functioning Scale (GAF) to the regulations adds unnecessary complexity and confusion. 4. Proposed Changes to the Definition of Traumatic Brain Injury in Children There are several concerns with this proposed change. a) What if there is no Level 1 trauma center in your area? b) What if your child is brought to the closest hospital emergency room but that hospital is not a Level 1? c) What if the child is released and not admitted? d) What if the CT/MRI does not show intracranial pathology but the brain injury symptoms are there? e) The same concerns we raised about family stress and caregiver burn out when adults are admitted to a rehabilitation center are intensified when there is a child admitted to the hospital.

5 Page 5 f) The Panel raised the issue of the children whose brain injury becomes more problematic with the fullness of time. Should these children have the benefit of being assessed under the adult definition of CAT to age 21? The Panel decided this was outside it s direct mandate and did not include this as a recommendation. 5. Interim CAT Status To reach the Interim CAT status you first must meet the definition of CAT. This raises all the concerns we have with the proposed change to the CAT definition. Further, it is unclear: a) whether the $1 million in medical rehabilitation is available under the Interim CAT status; b) when and how a brain injury survivor is assessed from Interim to CAT; c) in the event a brain injury survivor is not found to be CAT, what happens to the funds spent over the $50, Physical and Psychiatric Impairments not be combined for the purposes of the CAT definition The proposed change to the definition would require any impairment or impairments arising from traumatic brain injury, that could be classified as psychiatric, to be evaluated using the adult definition of CAT and not the Whole Person Impairment. This is completely discriminatory for brain injury survivors who may not fall into the severe disability upper or moderate disability lower criteria on the GOS-E. There is no reason why a brain injury survivor who sustains a mild to moderate brain injury resulting in psychiatric symptoms, along with a physical impairment should be excluded from being able to combine impairments. The Panel also indicated that it did not have the resources to conduct a comprehensive review of the literature to determine whether valid and reliable methods of combining physical and psychological impairments exist. The Panel recommends an Expert Panel consider these issues. OBIA would support this recommendation.

6 Page 6 Summary OBIA has grave concerns regarding the changes being proposed to the CAT definition and the impact it will have on those who are seriously injured in motor vehicle collisions. In September 2010, the Statutory Accident Benefits were reduced from 100,000 to 50,000 thereby broadening the gap between basic coverage and benefits available to those who are deemed catastrophic. It is our contention that the proposed changes are yet another step which will further restrict access to medical and rehabilitative care to those who are most seriously injured. These changes, if approved, will exclude survivors of brain injury from being deemed catastrophic, thereby negatively impacting brain injury survivors and their families. Furthermore, those who are seriously injured will quickly run through their $50,000 in med/rehab benefits and will be forced to turn to the public health care system, thereby putting further pressure on the already strained system. Additionally, if the injured person is unable to return to work they will have no choice but to turn to the Ontario Disability Support Program, Ontario Works and Canada Pension Plan. It is worth noting that the residents of the province of Ontario pay for insurance so when an unfortunate incident occurs, they are assured of receiving proper care and services. However, with the proposed changes, less will be covered by the insurer and more will fall to the burden of the taxpayer. The Ontario Brain Injury Association (OBIA) recommends that further consultation is needed before any changes are made. As an organization who supports brain injury survivors and family we request to be a part of future discussions and recommendations related to changes to insurance issues which involve brain injury and auto accidents.

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