Background
Evidence suggests injured people who claim compensation after a motor vehicle crash (MVC) do not recover as well as people with similar injuries who do
not claim compensation. There is an abundance of research supporting this view [
1]. However, while there have been questions raised as to the quality of some of these studies [
2], such as that results are confounded by self-selection of participants to the compensation or no-compensation group [
3], the consistency of evidence cannot be ignored. Reviews have found negative associations for both physical and mental health [
4,
5]. Furthermore, the evidence for the negative influence of compensation has been collected from a range of countries worldwide, and has included both workers’ and MVC compensation schemes.
Even though most research has suggested a relationship exists between being involved in a compensation process and poorer health following an MVC, few studies have investigated reasons why. Some researchers have suggested that people who claim compensation may have different personal characteristics than those who do not claim, such as a worse pre-injury health status or a different personality, and that these characteristics could contribute to poorer recovery [
5]. Others suggest the contribution of
secondary gain or
accident neurosis, which suggests that claimants do not recover because of a financial incentive not to get better as long as the process lasts [
6]. Finally, people involved in a compensation process could be impeded by the stress surrounding the process, including the adversarial attitude of legal professionals
(secondary victimisation) [
7,
8].
The current study further investigated the latter theory, that is, whether the compensation process is inherently stressful and therefore associated with poorer well-being. It considered the possible elements of the compensation process that increase stress and anxiety. Claim factors that have been found to be stressful are, among others: claim duration, involvement in legal disputes, and lawyer engagement [
7,
9]. Interestingly, the impact of the interaction with the insurance company, which could be considered to have the biggest effect on claimants’ well-being, has not been well investigated. To our knowledge, only two quantitative studies include the insurance company as a possible influencing factor on health and well-being [
8,
10]. They both concluded that the stressful interaction with insurance companies was the most important factor explaining elevated levels of anxiety in people who claimed compensation. Both studies recruited their participants from trauma hospitals, which implies that their participants are more severely injured than the general claimant population. Further research is needed to replicate this finding in the average motor vehicle compensation population. Certainly more research is required that investigates those aspects that are related to increased stress and anxiety.
To our knowledge, only two qualitative studies have investigated experiences of injured people with the insurance company [
11,
12]. It should be noted that there are a number of qualitative studies that address the interaction between injured people and insurance companies [
13,
14], but most examined injured workers in workers’ compensation schemes, a process likely to involve different issues than for people who are involved in a motor accident compensation scheme. The study by Murgatroyd et al. [
11] and Gabbe et al. [
12] are unique as they were concerned with the latter. Participants reported they found the claims process adversarial and stressful due to factors such as a lack of communication, problematic treatment approvals (e.g. it took weeks to approve treatment requests, and sometimes it was a fight to get approval), and negotiating settlement was gruelling (e.g. procrastinating for as long as possible to maximise financial hardship, pressuring claimants to settle for a lesser amount) [
11]. Delays in receiving benefits resulted in stress and financial hardship, and it was difficult to navigate through the claims process and the paperwork [
12]. While these findings are valuable and illustrative, the participants’ interaction with the insurance company was only a sub-element of the study.
In order to address this gap in knowledge, the aim of the current study was twofold. The first was to replicate the finding that the interaction with the insurance company is associated with elevated anxiety in a general claimant population. The predictor of primary interest is dissatisfaction with the claims management process by the insurance company. Also, to achieve this first aim, additional variables were included, such as pain-related catastrophising [
15] (that is believing that something is far worse than it actually is) and various claim factors (e.g. type of insurance company, lawyer engagement, previous claim, and claim settlement). The second aim was to establish why the interaction with the insurance company is perceived as stressful. To answer this research question, we explored the participants’ dissatisfaction with the insurance company in a thematic fashion, using qualitative analytical techniques.
Discussion
The first aim of this study was to replicate the finding that a stressful interaction with the insurance company is associated with anxiety [
8,
10]. The current study indeed confirmed this, showing that dissatisfaction with the claims management process was associated with increased anxiety at 2 and 24 months after injury. However, dissatisfaction with the insurance company was not the best predictor because pain related catastrophising was stronger. In the literature, catastrophising has been discussed as a cognitive component active in depression and elevated anxiety [
24]. However, the finding is a noticeable result
in the current context, because pain-related catastrophising has not been taken into account in prior compensation and health studies. This may have led researchers to over-estimate the impact of other factors on the injured claimants’ well-being, and to disregard the importance of cognitions. It is often thought that claimants’
coping style is important in recovery. Our finding suggests it is worthwhile further investigating whether this is the case.
Three variables were associated with anxiety/depressive mood at one measurement only. Pre-injury health was associated with anxiety/depressive mood at 2 months after injury, which is consistent with a previous finding of a study among claimants in a no-fault scheme in New Zealand [
25] and a study examining a general injury population after a motor vehicle accident in Victoria, Australia [
10]. Lawyer engagement was associated with anxiety at 12 months after injury, which confirms previous findings [
9,
26]. An explanation could be that the claims procedure becomes more adversarial when a lawyer gets involved [
27]. It could also be the case that a complex and/or confusing claims process contributes to anxiety, which encourages claimants to seek legal advice [
12]. Finally, women were more likely to report problems with respect to anxiety/depressive mood 24 months after injury, which has previously been shown in other MVC studies at 12 and 36 months [
28,
29]. It is unknown why women have a greater chance of developing anxiety after trauma [
29].
The current findings can be discussed in relation to the three explanatory theories described in the Introduction. First, the association between dissatisfaction with the insurance company, lawyer engagement, and the presence of anxiety/depressive mood may support the theory of secondary victimisation, because these were all claim factors associated with stress. Second, the factor ‘claim settlement’ was not associated with anxiety, so the current study does not support that claim settlement improves recovery (which would suggest secondary gain) [
6]. In contrast, our findings endorse the review by Mendelson, who concluded that claim settlement does not have an effect on the recovery outcome [
30]. Third, the significant associations found between anxiety/depressive mood, high catastrophising, and poorer pre-injury health could be relevant with respect to the theory that claimants have different characteristics compared to non-claimants and that these group differences are responsible for poorer recovery. However, to be able to draw a conclusion about the latter, a comparison between claimants and non-claimants is required; unfortunately, the current study included claimants only. There is a large prospective cohort study in progress that investigates this issue (trial registration number ACTRN 12613000889752).
The results should be interpreted with caution because of limitations. First, a selection or attrition bias could have been present. For example, there was an under representation of participants with limited education (2%), an over-representation of one insurance company compared to the market share, and those who withdrew from the study were significantly younger than the completers. Secondly, only a self-assessed, one-item subscale for the presence of anxiety/depressive mood was used, whereas a clinically administered questionnaire may have yielded more sensitive results. Furthermore, it is important to note that the current study consisted of an observational study design, and some confidence intervals are wide, so one should be careful not to draw conclusions about causality. Finally, not all measures that are possibly of influence to anxiety and depression, such as social support, were taken into account.
The second primary aim of the study was to (qualitatively) explore what is stressful about the interaction with the insurance company. Five themes were found: communication, determining compensation, medical treatment and assessment, paperwork, and liability assessment. Lack of communication, problematic treatment approvals, and the burden of delayed claims settlement, were themes that stood out as stressful and burdening. These results were also addressed as problematic in previous studies about the car injury compensation process [
11,
12]. Also noticeable was the reported financial burden that is associated with delayed payment, especially in case of loss of earnings, which, in fault-based schemes, is often compensated in the form of a lump sum award at claims settlement. Since claims settlement can take 12 or 24 months, a lack of income highly stressed some injured participants for a considerable length of time. The impact of delayed or interrupted payments has been reported in the workers’ compensation literature [
14,
31], and administrative delays were found to be positively associated with the odds of developing chronic disability [
32], indicating that this is a serious issue. A specific suggestion to relieve the stress of financial uncertainty is to introduce payments for loss of income after a qualifying period rather than by reimbursement at settlement only.
The problems with proving liability and causality were not discussed in qualitative studies previously, although they have been pointed out as risk factors potentially resulting in elevated stress in a literature overview [
2]. The extra stress seems to be preventable with better explanations as to why certain questions are being asked, faster treatment approval times and pre-payment for selected evidenced based treatments. Finally, the burden of too much paperwork has been discussed in workers’ compensation settings [
14,
31], although it might be a more prominent problem in the current setting, that is, a fault-based compensation scheme, whereas the previous workers’ compensation studies examined a no-fault scheme, in which people are eligible for compensation regardless of fault. It seems worthwhile to review the number and length of these forms, as well as to simplify questions asked, prevent duplicity and provide assistance with form completion. In NSW, the forms are currently being reviewed. Overall, it is concluded that many of the findings have already been discussed in other studies in different parts of the world describing either car injury or workers’ compensation schemes. The fact that these topics are recurrent topics described in a growing body of literature from different schemes all over the world shows the importance of the problem and the need for change.
The qualitative research has limitations. First of all, qualitative research, in general, is difficult to generalise, because the analysis focuses on individuals rather than group samples [
23]. Qualitative research cannot provide information about the frequency, or overall importance, of specific issues. A strength of this present study, however, is the large sample size, improving the generalisability of the findings. Secondly, the analyses deal with the perceptions of people who have made claims and therefore are not independently verifiable. Verification of the overall findings with the Motor Accidents Authority revealed that, for example, approval of treatments also needs to be in accordance with clinical practice guidelines, the time of day for medical assessments is not determined by the insurer but by the medical assessor, and that an independent claims advisory service is available to provide practical advice and assistance without cost to the injured person. Regarding the communication issues, claim managers officially have 10 working days to reply to requests, which is ‘a couple of weeks’, so that means the participant’s claims manager seems to have acted according to the insurance legislation and regulations [
16]. Similarly, common practice restricts claims managers from directly communicating with a legally represented claimant. Finally, it should be noted that the participants were involved in a hybrid, mainly fault-based compensation scheme [
33]. Most countries have a fault-based compensation scheme for injury after a traffic crash, but some countries or states have a no-fault scheme. One should be careful to generalise these findings to a no-fault setting, because fault-based schemes are hypothesised to be more adversarial.
Conclusions
Two conclusions can be drawn from this study. First, it was found that pain-related catastrophising is strong predictor of anxiety/depressive mood in people injured in MVC. This means that it could be beneficial to assess the injured person’s level of catastrophising in order to optimize treatment and to improve well-being. People who score highly on catastrophising may benefit from social or professional support addressing feelings of helplessness and hopelessness, and encouraging a problem-solving adaptive coping style approach with respect to their injury, pain and claim management process.
Second, this study found an association between claims management dissatisfaction and the presence of elevated anxiety/depressive mood. Stress was associated with problems of communication, medical treatment, and claim settlement. Overall, it seems that most problems reported by the participants could be mitigated if claim managers would adopt the attitude that they are the ‘problem owner’ and become more proactive. It is acknowledged that ‘improving communication’ is already on the agenda of many insurers, but ‘problem ownership’ is more than that. It is about taking responsibility for the fact that damage has been inflicted that now has to be mitigated, assessed and compensated. This can be achieved by a proactive form of claim management (e.g. taking the initiative in the interaction, frequent updates about the state of affairs, smooth approval of treatment, expedient reimbursement of incurred costs, and adequate interim payments of established compensable loss of income). Such an attitude could potentially restore the injured person’s feelings of injustice that harm has been inflicted to him/her [
34]. A previous study showed that a proactive approach by the insurance company facilitates the claimants’ return-to-usual-activities [
35]. This suggests that proactivity would not only be beneficial for injured people but also may imply a cost reduction for insurance companies.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made.
The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.
Competing interests
All authors declare that they have no competing interests.
Authors’ contributions
IC designed and implemented the study, KL collected the data, NE further developed the research questions and analysed the findings, AA provided legal interpretation of data, AC gave important feedback from a clinical psychologist perspective; NE drafted the paper. AC, IC, KL, and AA critically revised the paper. All authors approved the final version of the manuscript.