Assessing Pediatric Catastrophic Impairment under Ontario's Statutory Accident Benefits

When a child has suffered a traumatic brain injury and/or catastrophic muscular-skeletal injury resulting from a motor vehicle accident, a parent or guardian may seek the status of Pediatric Catastrophic Impairment under Ontario's statutory accident benefits (SABS). Claimants who meet this definition have access to a higher level of maximum benefits for medical and rehabilitation services, attendant care, case management, and other related goods and services.

The first step in applying for this status is for the clinician treating the claimant to seek a catastrophic impairment designated assessment centre (CAT DAC) assessment to determine whether the claimant qualifies for this higher level of benefits. This is usually initiated if a catastrophic impairment status is denied the claimant by his/her insurance company. This assessment is not a determination as to whether a specific benefit is reasonable and necessary but merely an assessment to determine one's status. In addition to a claimant requesting this classification, an insurer may request a CAT DAC in order to more fully assess a claim.

Consulting with the medical community is a key element in Ontario’s reformed insurance guidelines in order to more accurately determine who qualifies for benefits under the definition of “catastrophic impairment” in the Statutory Accident Benefits Schedule (SABS). Team members including a psychiatrist, family physician, or general internist, among others, generally assess the catastrophic impairment criteria to be applied to a person by reviewing the claimant's file and give their recommendations.

Children with Traumatic Injuries

Determining whether or not a catastrophic impairment applies to a child represents a special set of challenges. Clinicians must apply the same set of criteria used to assess adults to determine if they are synonymous for the condition with the condition of the child. A full description of the assessment criteria is outlined in Section 40 of the SABS.

Automatic Inclusion

A child (i.e. under the age of 18) with a pediatric traumatic brain injury is automatically deemed to have sustained a catastrophic impairment if the child is admitted to a Level I trauma centre, has a positive CT scan and as a result of the accident, has sustained contusions, hemorrhages, edema or other accident-related trauma. A determination of pediatric catastrophic impairment on the basis of traumatic brain injury includes the inability of a patient to communicate verbally or non-verbally or to respond to commands, or has non-purposeful movements of limbs or eyes within the first 3 months after the accident. Also, the diagnosis is catastrophic impairment if after 6 months, a child is not able to respond to commands with movements of the eyes or body parts or unable to carry out a self-care activity such as bathing and feeding themselves.

Providing goods and services that are reasonably necessary is the standard the Ontario government has set with regards to statutory accident benefits available under vehicle insurance.  Certainly, children who suffer a catastrophic injury are the most effected by an accident and require the most substantial financial support for care and recovery.  In terms of medical, rehabilitation and attendant care benefits, adults and children are eligible to receive the same maximum benefits; however, for children who sustained a catastrophic impairment, the benefits are available for their lifetime.

Sources: https://www.fsco.gov.on.ca/en/auto/autobulletins/archives/Documents/a-09_01-1.pdf

http://www.fin.gov.on.ca/en/autoinsurance/si-report.html#sr11