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Effect of Eliminating Compensation for Pain and Suffering on the Outcome of Insurance Claims

(Med författarens medgivande)

The New England Journal of Medicine -- October 12, 2000 -- Vol. 343, No. 15

To the Editor:

The findings of Cassidy et al. (April 20 issue) (1) suggest that radical changes are needed in the tort system of automobile insurance that is common throughout the United States, in which injured claimants can sue for pain and suffering caused by another driver's negligence. Cassidy et al. examined the time to closure of a claim for claimants injured in motor vehicle collisions in Saskatchewan, Canada, during the six months before January 1, 1995, when a tort system was in effect, and in the two consecutive six-month periods after that date, when no-fault insurance was implemented. Under the no-fault system, claimants could no longer claim compensation for pain and suffering. The time to closure of claims was reduced by 54 percent during the no-fault period. The authors conclude that the reduction in the duration of whiplash injuries under the no-fault system was due to the absence of the financial incentive that is inherent in the tort system.

Cassidy et al. base their conclusions on the assumption that when an injury claim was closed under the no-fault system, the claimant had recovered from his or her injuries. The only support that Cassidy et al. provide for the assumption that recovery from whiplash coincided with the closure of the claim is a 1995 monograph by the Quebec Task Force on Whiplash-Associated Disorders, in which the authors equated the cessation of time-loss payments with recovery. (2) We have criticized the use of time-loss payments as a proxy for recovery in that study, since no data were collected on the symptoms, amount or type of treatment, or degree of functional impairment of the injured study subjects (3); thus, there was no evidence supporting the conclusion that they had actually recovered. Cassidy et al. have made the identical error in the current study. Curiously, they recorded the level of pain in the study subjects but chose not to report these data in their article.

A closer examination of the no-fault insurance system in Saskatchewan reveals several other changes that contributed to the more rapid closing of claims after the no-fault system was implemented. These changes confounded the data the authors relied on for their conclusions. For example, under the no-fault system, patients with symptoms that persist far more than six weeks are referred to centers that are owned and managed by Saskatchewan Government Insurance, for evaluation and rehabilitation. If the claimant refuses the insurer-mandated treatment, the claim can be closed by the claims adjuster, under the no-fault statute. In addition, with the elimination of virtually all litigation, there is no need to have claims remain open for the resolution of any legal issues.

What Cassidy et al. have demonstrated with their study is that if an insurer is given the ability to close claims more rapidly, the insurer will do so. This finding does not come as a great surprise. The ultimate effect of this experiment on the health and welfare of the people of Saskatchewan has yet to be determined.

Michael D. Freeman, Ph.D., D.C., M.P.H.
Oregon Health Sciences University School of Medicine
Portland, OR 97201

Annette M. Rossignol, Sc.D.
Oregon State University
Corvallis, OR 97330

Editor's note: Dr. Freeman has been a consultant and has provided expert testimony with regard to motor vehicle-collision injuries for plaintiff and defense attorneys, as well as law-enforcement agencies.


1. Cassidy JD, Carroll LJ, Cote P, Lemstra M, Berglund A, Nygren A. Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury. N Engl J Med 2000;342:1179-86.
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2. Spitzer WO, Skovron ML, Salmi LR, et al. Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: redefining "whiplash" and its management. Spine 1995;20:Suppl:1S-73S. [Erratum, Spine 1995;20:2372.]
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3. Freeman MD, Croft AC, Rossignol AM. "Whiplash associated disorders: redefining whiplash and its management" by the Quebec Task Force: a critical evaluation. Spine 1998;23:1043-9. 

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