If insurance coverage is denied, the headinjured person cannot benefit from appropriate treatment and the insurer mav end up paving more than is necessary because the patient remains at the wrong facility. When head injurv programs can demonstrate that aggressive rehabilitation treatment for the severely head injured improves outcome and lessens the chance for long-term institutionalization and rehospitalization, insurers may pay because such treatment will cost the insurer less money in the long run than a traditional program that falls within the terms of the insurance contract. Because many head injury programs are housed in facilities that are licensed as skilled nursing facilities, insurance companies are reluctant to pay for such treatment contending it is custodial in nature. When medical records contain proven evaluation data demonstrating a patient's improvement over time, an insurance company is hard pressed to deny coverage on custodial grounds. Functional assessment affects compensation litigation that head-injured individuals may seek in order to choose optimal treatment.
Successful pursuit depends on the particular paitient's response to continued aggressive treatment.
Assessment evaluations give an insurance company, a jury, or an administrative law judge concrete evidence of the need for and the benefit of continued treatment. If well researched, this evidence will persuade a fact finder who will order that compensation be given to the injured individual so that he or she can obtain the needed treatment. In conclusion, the growing area of functional evaluation will validate rehabilitation efforts and greatly improve the legal rights of persons with head injury.