Opinion: SGI restricting claims related to concussions from collisions

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As public awareness grows about the importance of recognizing and treating concussions in sport, SGI’s approach to claims relating to motor vehicle collision related concussions seems to be getting more restrictive.

When SGI clients are injured and need treatment, they typically see a doctor or primary care provider who establishes a diagnosis and an initial treatment plan. If benefits like physiotherapy, chiropractic care or massage are recommended, clients work with their SGI representative for the necessary approvals.

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The initial diagnosis is usually accepted by SGI, with a standard set of approvals for most types of injuries. When an injury includes a concussion, however, SGI has imposed a higher degree of scrutiny.

In 2023, SGI lost two appeals at the Automobile Injury Appeal Commission relating to benefits for concussion or concussion-like symptoms. In one, the commission found that an appellant’s concussion-like symptoms were accident-related and treatment was wrongly terminated.

In another, the commission found that a neurologist’s diagnosis of concussion should have been accepted by SGI, which had instead relied on opinions of its consultant ER doctor and psychologist. These decisions reflect SGI’s broader failure to properly manage and fund benefits for recovery from concussion symptoms.

As we understand from the medical community, most concussions resolve quickly and without lasting effects. Some, however, require further treatment and management.

Rather than broadening its approach in response to these decisions, SGI has adopted a policy that not only restricts concussion treatment, but also protects SGI against losing similar appeals in the future.

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We at the SGI Appeal Advisor Program have noted that SGI now requires every diagnosis of concussion made by an ER or family doctor to be confirmed by SGI’s psychology consultant before treatment is approved.

This approach is inconsistent with SGI’s treatment of other injuries, where initial diagnoses by medical professionals are generally regarded as reliable.

Although clinical psychologists can only diagnose mental and not physical conditions according to their professional regulations, SGI has determined that the same few psychologists are best suited to decide, based only on a file review, whether a concussion has occurred.

In most cases where there was no observed and documented loss of consciousness, the diagnosis is refuted.

Without seeing a patient, psychologists discount symptoms like headaches, fatigue, light sensitivity and dizziness as being caused by something other than a concussion, citing a lack of objective proof that the people hit their heads in the motor vehicle collision.

The fact that these symptoms arise in the general population for a variety of reasons makes it even more important that we entrust medical professionals to make a diagnosis: to examine patients, to ask the patients questions about symptoms and about the collision, and to use their professional judgment to arrive at the most likely explanation.

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It should not be enough to have a file review by SGI’s preferred psychology consultant to deny the diagnosis, yet this practice has been upheld by the commission.

Although it is accepted that some concussion patients will have a prolonged recovery, SGI limits its benefits to those individuals by routinely denying their diagnosis at an early stage.

By ensuring that the denial comes before any recommended treatment is provided, SGI also prevents information documenting symptoms, assessments and recommendations from treatment teams from being recorded on the client’s file.

At an appeal, there will be little file documentation of an individual’s symptoms, and unrepresented appellants will still likely lose even if they can convince a doctor or neurologist to attend and testify on their behalf.

SGI will attend with a lawyer and one or more expert witnesses who will present a refrain that Saskatchewan doctors are overly sympathetic and make diagnoses based only on what is reported to them by their patients.

Benefits for many cases of mild traumatic brain injury are effectively excluded from SGI coverage, and physicians are discouraged from objecting to a system that assigns so little value to their medical opinions.

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Robin Burlingham is the director of the SGI Appeal Advisor Program, a branch of the Ministry of Justice that provides assistance and advice to SGI clients who have appealed an SGI decision relating to personal injury benefits to the Automobile Injury Appeal Commission.

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