Taking stock of rehab

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The effectiveness of rehabilitation has been a hot topic among firms in the insurance industry but what are the processes that need to be taken into account to ensure it really takes off? Anthony Gould reports

Rehabilitation has been talked about for years across the insurance industry, yet take-up is still patchy. The effectiveness of rehabilitation was one of the key themes to emerge from a recent Post roundtable event, held in conjunction with Corpore, which also touched on how the cost of rehabilitation could be improved, speeding up delivery and identifying who would most benefit from the process. To kick off the debate, the panel of experts were asked: "Is rehabilitation working for you?"

"No, is the simple answer," responded Bob Still, customer services director at MMA Insurance. "Rehabilitation is something that we talk about with great enthusiasm but to get it into the front line for low-value claims is not really any easier today than it has ever been."

This sentiment was echoed by Roy Hebburn, technical claims manager at Allianz Cornhill, who said: "We have an adversarial system and an NHS that does not promote rehabilitation. As insurers, we try to promote it because it is sound business sense. However, there should be an obligation on the part of the injured person and on the NHS to ensure that effective rehabilitation is not only given but taken."

Positive results

"I disagree," interjected Julie Woolsey, rehabilitation and claims controller at NFU Mutual. "Despite reservations and restraints, our return-to-work programme has been operating for about 10 years with improved results year-on-year. We also launched a soft-tissue programme recently - which is in its infancy - but again we are seeing positive results early on."

"I wouldn't disagree," retorted Mr Hebburn, "but if it were not an adversarial situation, the results that all of us achieve - because we also achieve positive results - would be far better."

Perhaps unsurprisingly, views were unanimous that the key to successful rehabilitation is to get the door open early; that is, to receive early notification of any claim or injury, be it catastrophic or minor, employers' liability or motor. "Finding out about these incidents in the first place is probably the biggest barrier to rehabilitation," asserted Ms Woolsey.

Steve Maddock, claims director at Royal and Sun Alliance, concurred: "Unless we can get hold of claimants at the earliest possible stage, then we are handicapped in terms of being able to prescribe effective treatment."

The adversarial legal system came up in the discussion time and time again. David Lee, senior liability adjuster at Brit Insurance, said: "Even when you are notified, as soon as a claimant's lawyer comes on, they literally try to put a stop to the rehabilitation. They have never come back with a reason we can't use rehabilitation - because it is a win-win situation for everyone - yet it often takes nine months for them to agree to it."

He continued: "We find that for our low-end whiplash cases, more than half the people that we offer physiotherapy to through their solicitors turn around and say no - and they usually can't identify a true reason for it."

This theme was continued by Spencer McCabe, manager of the medical management centre at Zurich, who said: "Solicitors say their claimant is happy with the NHS treatment. We say we are quite willing to supplement that with additional treatment, and they still reject it because, in effect, it takes away some control from the claimant's solicitor."

Ms Woolsey agreed, adding: "If you manage to get your rehabilitation provider in the same room as a claimant's solicitor, that tends to work as a last resort. We use independent occupational therapists and, if we can't convince the claimant's solicitor, we ask them to flag up the benefits."

The conversation constantly returned to the same theme, as Mr Hebburn commented: "Where we deal direct with claimants, we are able to not only close the claim more quickly but at a reduced cost. That is not from denying proper compensation but because the additional costs from our adversarial process are simply not incurred."

Ms Woolsey added: "We have a duty in our industry to manage those costs and, like some other insurers, have a pilot to capture policyholders on the soft tissue cases. If we treat them properly and give them adequate compensation in addition to rehabilitation - if required - there is going to be some cost saving and at least we can justify that we are looking after our policyholders."

In the absence of any claimant solicitors, Mr Lee put forward their case and said: "One of the big reasons claimant solicitors argue that they should continue to be in the picture is they provide a service to injured individuals and, if it was not for them, injured individuals would not be getting the necessary advice and care that they require. If we can demonstrate that rehabilitation can be of benefit to individuals - and it is crucial that we do - then we can to an extent defeat one of their major arguments, which is that they are required in the process."

Another factor clouding the issue, said Mr McCabe, is that "the drivers for some solicitors are different to yours and mine and their clients, with commissions and referral fees being paid to lawyers from rehabilitation providers".

Mr Maddock summed up the feeling, and said: "Rehabilitation should not be a political football. At the moment, all of our debate is around control, with claimants a sort of secondary consideration. Yet our evidence suggests that the only way we can look after them is if we get in there early enough."

However, the adversarial legal system was not the only barrier identified by those gathered. "A lot of our employers' liability claims come from one or two-man bands," said Mr Still, "and being injured is simply treated as an occupational hazard. We find getting rehabilitation into those cases difficult because there is no appetite for it, as a lot of these people see the lump sum at the end of it as their win-win. They are not interested in rehabilitation because they have the NHS, which they are being treated by anyway. So the actual motivation has to come from a much wider sphere than just us."

It was suggested that this is where some form of compulsion could play a role, in that if a claimant declines rehabilitation, it should be reflected in the final damages awarded. However, it was also recognised that the main issue was one of trust or, rather, a lack of it. As one delegate said: "Isn't the problem confidence? The insurance industry is associated with endowments and various life insurance policies. We have talked about solicitors having financial interests in our clients but let's be blunt - we have a financial interest too. They are going to say we are only doing this because we are hoping to keep the damages and costs down."

Language barriers

Mr Hebburn suggested that the language used by insurers does little to help the situation, to which Carl Woodbridge, managing director of Konekt (Australia) replied: "So why not change the heading of your policy from 'employers' liability' to 'appropriate care for employees'?"

Nick Patterson, managing director of Corpore, added: "We don't use the word rehabilitation; we use the terms 'injury management' and 'return-to-work process'."

Another main theme to emerge from the roundtable discussion was how to justify investment in providing rehabilitation - in black and white, hard figures - especially on low-value claims, where there is a lack of genuine cost-benefit statistics across the insurance sector.

Geoff Leeks, claims and technical services manager at Royal Bank of Scotland Insurance, commented: "In motor, you know about the accident pretty much from day one. Traditionally, we have been relatively successful at the higher end, like most other insurers - now we are trying to improve our processes at the low-end."

Nick Gunter, technical claims manager at Fortis, added: "One of the biggest troubles that we all share is demonstrating that there is a financial benefit. Every penny we spend on the rehabilitation process has to see some sort of return in order to justify it because we are talking about small sums of compensation.

"Some people measure their savings on rehabilitation in a way that is not a saving to me. I spoke to one company that included the legal costs it was not paying the lawyer when it contacted the claimant direct. They said, 'the average we would have paid the claimant lawyer would have been X, so that is our rehabilitation saving'. If companies persist in having a measurement like that, it is hopeless. I agree it would help if we could pool our collective examples in rehabilitation to see whether there is evidence that it works - some people claim it does but how do they measure it?"

Mr Leeks added: "The crucial thing is ensuring that you have identified the right individuals. Our concern is the push for a blanket approach to every individual whiplash injury. It is key that we identify at the outset those that will really benefit from some sort of rehabilitation intervention. However, it is not easy."

Mr Maddock said he shared this concern about taking a blanket approach "where you tear out several (physiotherapy) vouchers and say 'off you go'. As an industry, do we really understand the cost game? Do we understand whether it works and what the cost benefit is and where it is? For us, it is how you deliver effective treatment, depending on the individual circumstances".

Mr Hebburn added: "Insurers have to be selective in terms of the cases that they look to intervene on because if you take the blanket approach, it is probably going to drive up the cost of claims anyway."

Third-party sources

The role of service providers was also addressed with one guest confirming: "We have had several approaches from third-party sources who are keen to lock us into arrangements around the provision of rehabilitation. However, that comes back to the point where we are then handing over control, saying OK, put every single one of your claimants through an assessment process and we will pick up the bill."

Mr Hebburn added: "That is rather more about cost-building than putting claimants at the centre of the process. It is a leap of faith - sometimes you have to put liability to one side and invest in what is right for an individual, be it rehabilitative, getting them back to work or just some injury management."

It was generally agreed that one of the key issues that remains is how to identify those cases where there will be some benefit from rehabilitation and then acting on those. "The more multiple parties you have - the more process - the more expensive it becomes," said Mr Maddock. "As an industry, we are going to have to move this debate away from political footballs and onto what really matters. We have to start to share some of the evidential information if we are to lobby government for change."

Mr Still added that, in a standard motor book, the opportunity is not there for the majority of claims. "We have tried various schemes and each one of them costs us more money than if we had just settled it. However, we find the adversarial aspect is the single stopper for the moderate-sized claims."

Mr Woodbridge stressed that it comes down to being able to identify the cases that can benefit from rehabilitation because there are certain types of injuries and people that respond better than others from its application. "If you are in there early and you are co-operating and appearing to be conducive to supporting claimants in their return to work or return to fitness, it completely alters an injured person's behaviour," he said. "However, if you wait till week six, doctors are not prescribing anti-inflammatories and painkillers - they are prescribing anti-depressants. So you are not just treating the injury any more, you are treating something completely different."

In the final analysis, there was a widespread consensus that rehabilitation has major potential but that the industry should share its experience if it is to understand the real cost benefit. Part of this process is, of course, being able to identify exactly which claimants will benefit from rehabilitation - and who won't. On an altruistic note, however, one delegate said: "How powerful would it be if you could say 'actually, there is no cost benefit around rehabilitation, it is about providing the best outcome for customers'?"

- NICK GUNTER, technical claims manager, Fortis

- ROY HEBBURN, divisional claims manager, Allianz Cornhill

- DAVID LEE, senior liability adjuster, Brit Insurance

- GEOFF LEEKS, claims and technical services manager, Royal Bank of Scotland Insurance

- STEVE MADDOCK, claims director, Royal and Sun Alliance

- SPENCER MCCABE, manager of the medical management centre, Zurich

- MIKE NOONAN, head of claims management, QBE

- NICK PATTERSON, managing director, Corpore

- MARTIN SPRY, non-executive chairman, Konekt (Australia)

- BOB STILL, customer services director, MMA Insurance

- CARL WOODBRIDGE, managing director, Konekt (Australia)

- JULIE WOOLSEY, rehabilitation and claims controller, NFU Mutual

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