Serious burn cases, by virtue of the impact these injuries can have on many bodily systems and functions, may require health care professionals to come up with creative recommendations to maximize the patient’s reintegration into former lifestyles and vocations. Under Bill 59, the insurer is required to pay for all reasonable and necessary measures that reduce the effects of any disability and assist in the injured person’s reintegration into family, society and employment. As illustrated by the case below, this may allow health care professionals considerable leeway in devising innovative solutions to better serve the rehabilitation needs of burn victims.
In an arbitration decision decided in 1998 (see Zettler v. Pilot Insurance Co.,  O.I.C.D.No. 52), the arbitrator considered what the insurer’s obligations were to Mr. Zettler, a farmer who had sustained serious burns, among other injuries, in a motor vehicle accident. While this case was concerned with a claim under Bill 164 (the previous legislation), the findings are equally applicable to the current regime under Bill 59.
Mr. Zettler’s injuries included very serious burns to the left side of his face, resulting in the loss of his left eye. Extensive burns affected his upper body and the top of his head. As expected with serious burns, Mr. Zettler had to endure multiple skin grafts and reconstructive surgery to the damaged tissues. Ultimately, he was left with permanent disability, including an inability to lift heavy objects, restricted movements of his left arm and shoulder, difficulty breathing in dusty locations and a sensitivity to temperature changes affecting his face and neck. These ongoing symptoms were particularly problematic for a relatively young man who was intent on returning to his farming job.
Rather extensive accommodations were recommended to facilitate Mr. Zettler’s return to farming, including: a new pickup truck with added options of automatic transmission, push-button overdrive and bucket seats with a lumbar support; a new tractor equipped with a dust-free enclosed cab, special seats, air conditioning and heat; and, a 16 gauge air nailer to help him resume his hobby in woodworking. Other items were recommended as well.
In determining entitlement under the rehabilitation section of the benefits schedule (then section 40, now section 15) the arbitrator pointed out that in determining whether a measure is “reasonable”, cost does not necessarily have a bearing. Much of what was claimed for Mr. Zettler was quite expensive, but had no bearing ultimately on the arbitrator’s findings. Mr. Zettler was allowed the cost of the pickup truck, less the trade in value of the old truck. Likewise, the arbitrator allowed the claim for the new tractor, less the trade in value of the old one. Pilot Insurance was also required to pay for the air nailer.
This case illustrates how broad the obligation of the insurer can be for rehabilitation benefits, particularly for burn victims who inevitably suffer disabilities that affect multiple body functions. A creative approach by health care professionals to identifying means to mitigate the effects of these limitations both at home and at work, whatever the cost, will help to achieve the most effective reintegration of these victims into their pre-accident lifestyles. While cost does not necessarily play a role in determining the reasonableness of a request for payment, under Bill 59 all lawyers and health care professionals must nevertheless be mindful of the fact that there are limits in the amount of money available. Burns are very serious injuries, but may not always be considered catastrophic. If not catastrophic, the medical and rehabilitation benefit has a ceiling of $100,000, an amount that can be quickly exhausted. Moreover, the need for accommodation might be immediate, but the determination of whether the injury is catastrophic may be delayed. As well, these benefits, in non-catastrophic cases are only available for 10 years.