Evidence-based Claims Adjudication of Traffic Injury Claims in Ontario: Shifting the Focus from Cost to Care

Abstract

Background.— In the Ontario automobile insurance system, claims adjusters decide whether to approve, partially approve or deny funding for clinical interventions submitted by healthcare practitioners. Typically, these decisions are made based on cost, without considering the evidence on the effectiveness and safety of the interventions. Objective.— Develop an evidence-based claims adjudication framework, which can be used by automobile insurers to integrate clinical evidence into claims adjudication. Method.— We adapted the evidence-based medicine framework developed by Sackett et al1 to develop a framework for evidence-based claims adjudication. Conclusion.— An evidence-based claims adjudication framework may help insurers make claim decisions that will promote recovery of individuals injured in traffic collisions and reduce claims costs. The effectiveness and implementation of the framework needs to be evaluated.