Terms and Conditions for referral for Assessment/Treatment services


#1

Terms and Conditions for referral for Assessment/Treatment services to providers. How do Insurers get away with these agreements?
Your insurer has a treatment provider call you to book an appointment to start treatment for physio, psych. or vocational. Those providers have a duty and obligation to you as the patient.
So how do agreements between the provider and Insurer state that services are being provided to your Insurer and not you?

Clauses like: The following are the terms and conditions for referral of services. These terms and conditions apply at all times with the respect and provision of you or your agent to “the insurer”.

And additional provisions that gives ownership and legal rights over medical reports and the insured’s (your) personal information. Even if the reports are requested by your Insurer to be destroyed?

Can your Insurer contract out a claimants right to privacy and right to access their personal information without telling you or without consent?

I don’t see how that can be legal? Two parties can not enter into a contract that violates another person’s rights?

Are these standard agreements that have just never been challenged?


#2

Insurance policies are recogized at law as a special type of contract. Group insurance contracts between the insurer and the policyholder do affect the rights of third parties (employees / covered persons). This is allowed and the rules for such group policies are set out in the insurance act of each province. As long as insurers comply with the requirements of the insurance act for group insurance policies, then they have broad powers to create clauses that limit the rights of group members.

Keep in mind that in most cases the insurance company DOES NOT impose these clauses on Policyholders (Employers), rather they present the employer with a buffet of options and the employer chooses what version of they policy they want. If they want to pay less, then they go for policies that have more restrictive clauses.

Really its the employer you need to lobby to get a better insurance policy, not the insurance company. Most likely it was your employer who chose to go with the badly worded policy so they could pay less.


David Brannen

Disability Lawyer with Resolute Legal

The response posted above is based on the limited factual information made available and is not intended as a full and complete response to the question. The only reliabile manner to obtain complete and adequate legal advice is to consult with a lawyer, fully explain your situation, and allow the lawyer enough time to research the applicable law and facts required to give an adequate opinion. The basic information provided above is intended as a public service only, a full discussion with a lawyer should be done before taking any any action. The information posted on this forum is available to the viewing public and is not intended to create a lawyer client relationship with any person. Answers from lawyer moderators are provided for informational purposes only, you should consult with your own legal counsel before taking any action that could affect your rights or legal obligations.


#3

This is not under the group contract.

Your Insurer refers you to treatment providers which they fund under your rehabilitation expense benefit. Without your knowledge, the treatment provider and Insurer enter an agreement that your Insurer dictates that they have first right to your medical records/reports from the providers. The Insurer contracts that they can dictate how your medical records are handled, destroyed, shared and if necessary the Insurer can seek a protective order on the providers medical records/reports that relate to the Insured.

The insured/claimant is not told that his personal information and medical records are being sold by the treatment providers to be controlled and under sole custody by the Insurer.

So a claimant is told he/she can not access their own medical info because the provider sold all their medical records and reports to your Insurer (as per the contract they have with the Insurer)

I say that is illegal.


#4

I guess, the heathcare is regulated. There must be a way to complain about the particular doctor’s behavior if he/she refuses to release your records.


#5

You could file a complaint but health care providers are self regulated so you may end up spinning your wheels.We have decided to litigate.

Who owns the treatment providers file? Usually, a psychologist that provides counselling or an independent health professional owns the record or file containing treatment information
about the client and medical reports.

Except… when the Insurer and their chosen treatment provider have contracted with each other otherwise. ie:
With some contracts, the health professional’s file is deemed the property of and under the control of the Insurer organization, even though it can be kept in safekeeping at the health professional’s office.
With others, the professional is required to submit the client’s file to the Insurer without keeping a copy.

Now who would agree to assessment/treatment when your confidentiality and privacy are not protected? Your psychological tests, clinical notes and reports are sold and controlled by the Insurer. Now your Insurer can not release them to you
because its too sensitive and you need a Doctor to interpret it all to you. So now, without your consent they send your psych reports to your Doctor.

The psychologist guaranteed everything you talked about would be confidential. Guaranteed that if the Insurer wanted to know anything that he would call you first. In our case he volunteered that he had semester long courses in blacking out information and paper shredding. (For real)

You are not off work for any mental health claim. So that is part of why we are suing.


#6

Sounds complicated. I didn’t get to the point when they ask to see their doctor but that moment will eventually come. I’ll have to consult with a lawyer then.

For now, they sent some forms to my doctor asking if my condition “stabilized”?
What does “stabilized” mean? It was a bit confusing. My doctor just said “no”. What does happen when the doctor responds “yes”? Does it mean you have to go back to work in the same capacity without any accomodation, work modifications or rehabilitation?

Obviously the language they’ve used in their forms so far can be interpreted in multiple ways and they are quite confusing for both me and my doctors.


#7

Stabilized means injury or disease or mental health from which little if any immediate change is expected. That your condition is not expected to get any worse or have any further problems.
You sound like you have a very supportive Doctor. If they asked that you apply for CPP-D I am surprised that they just sent some forms to your Doctor to fill out. If the Doctor said your condition was stable they may try to
have you try some form of rehabilitation.


#8

Is there anything else they are supposed to send?

I thought they would just send me a return to work schedule and off you go.

Rehabilitation would be nice but I am not sure they want to spend any extra money. They were trying to “dump” me back on my employer’s shoulders. But my employer refuses to make any accomodations as obviously they don’t need “unhealthy” people around. So none of them want responsibility.

I am hanging in there somewhere inbetween …


#9

Rehabilitation is not that nice. You would be in a better position if you have health benefits to plan out your own rehab.