Former SGI appeals advisor program director calls for change in appeals process

Former SGI advisor criticizes appeals process WATCH: A former director of SGI's appeals advisor program says there is a systemic problem with how insurance claim appeals are handled.

A former director with the SGI appeals advisor program says she’s frustrated with a program that was designed to simplify the appeals process for auto injury claims.

Robin Burlingham was an appeals advisor with the Automobile Injury Appeals Commission (AIAC) before becoming a director with the province’s SGI appeal advisor program.

But she found several concerns that seemed to favour SGI over the appellants in an injury claim.

“In Saskatchewan, the no-fault insurance system that we have with SGI is really different,” said Burlingham. “And that no-fault insurance system requires that we are able to place a higher level of trust in the government of Saskatchewan, in SGI, to be providing benefits where benefits are entitled. Because the whole premise of no-fault is that we don't want to have these really high litigation costs.”

Burlingham says the AIAC acts as a tribunal when a decision is handed down from SGI. Someone can appeal the decision in court or choose the tribunal that has been set up by the government to be an easier, cheaper way to solve appeals.

While Burlingham says people represented by her office were having more success than those who were not, she found the process to be rigid and sometimes combative.

“Because of SGI’s approach to them, the hearings are a lot more like court than other tribunals would have,” she said. “We were seeing SGI is sort of creating this system or modifying it to be more litigious in my opinion. Bringing the lawyers, and the lawyers can be aggressive, bringing expert witnesses, relying on case law and precedent, objecting to different issues. These took a lot of work and resources from our two-person office, and so resources were a question.”

SGI responded to a request for comment regarding the resources allocated to the program.

“The funding arrangement is intended to ensure the appeals advisor program is arms-length from SGI. SGI pays for the program because SGI collects the premiums for the insurance program it relates to.”

Burlingham alleges those who didn’t fall in the middle of the recovery bell curve were denied benefits they may have been entitled to. She alleges SGI would have consultant doctors refute appellants’ injury claims or the diagnosis of family doctors or hospital emergency rooms, including the opinion of psychologists to assess or diagnose a concussion.

“You have SGI hire a doctor who says concussion is way overdiagnosed in [emergency rooms],” said Burlingham. “Well, what can we do to inform doctors about what SGI wants to see for the practice? What tests do they want to have run at those initial stages so that the information can be properly documented?”

In an email to CTV News, SGI says it has used the same concussion protocol since 2015.

“SGI works with numerous qualified medical experts, including psychologists and neuropsychologists, who provide opinions based on the comprehensive medical information provided in a file, not diagnoses.

“SGI consults psychologists for opinions on concussion diagnoses due to their background in scientific methodology, knowledge of the interplay of biopsychosocial factors, and knowledge of human behaviour, emotion, and cognition. Symptoms such as headaches, fatigue, light sensitivity, and dizziness may overlap with Whiplash Associated Disorder and therefore SGI needs to distinguish between diagnoses.”

While she understands the position of SGI, Burlingham says the research around concussions specifically is constantly evolving.

“We don't want to be giving benefits to people who are not really entitled to those benefits, but we have to listen to the people who know the most about it, and we're just not,” she said.

After raising concerns internally without any results, Burlingham wrote an editorial piece in the Star Phoenix. She says she was later suspended for six weeks without pay.

“I was hurt by that,” she said. “I did feel that the concerns that I was raising were well understood and that they were legitimate and that others understood and agreed with me, but that there was no support at very high levels within the government.”

The Ministry of Justice declined to comment on the employment history of personnel.

“SGI and the Ministry of Justice & the Attorney General are working together to ensure the ongoing effectiveness of this program and provide our customers with the support they need. Our goal over the last year has been to simplify the appeal process for injury claims and bring efficiencies to the work done by the Automobile Injury Appeal Commission. We are making changes in a phased approach to avoid making the program more complex and to collect data along the way so we can make smart changes as the program evolves,” SGI statement read.

Burlingham has since resigned from her position.