Last week, I explored some of the reasons why some insurance companies fail to provide an aggressive defense for their clients.

The article pointed out the problems of obtaining malpractice insurance from a company that doesn't thoroughly understand chiropractic, particularly one which is owned or operated by medical doctors.

Often, these companies are far more familiar with medical concepts and wrongly apply them to doctors of chiropractic.

The result is that they often have doubts as to the 'innocence' of the D.C., and those doubts can steer them to settle out of court or engage in a weak defense effort.

The solution would seem simple -- find a company owned and operated exclusively by and for chiropractors. But it isn't as easy as it sounds. There are very few financially stable insurance programs handling only chiropractic clients. Even when dealing with the handful of companies that cater to D.C.s, there is another factor to take into consideration: what 'type' of chiropractic do they represent.

In chiropractic, as in most other health care professions, there are several distinct schools of thought represented by different organizations and practice guidelines. This is true even for the medical profession, which is divided between the ultra-pharmacological camp represented by the American Medical Association and the more holistic paradigm promoted by the Association of American Physicians and Surgeons.

In chiropractic, the camps are often categorized as the medically oriented 'chiropractic physicians' group and the non-medical subluxation-based chiropractic faction.

The former is primarily associated with the Mercy Guidelines (officially named the "Guidelines for Chiropractic Quality Assurance and Practice Parameters"), while the latter is associated with the Council on Chiropractic Practice (CCP) Guidelines ("Clinical Practice Guideline Number 1: Vertebral Subluxation in Chiropractic Practice").

D.C.s easily recognize the problem of having an M.D.-oriented company defend them in court. But they often don't realize the challenges of obtaining an aggressive defense from a company aligned with a set of guidelines they themselves don't follow. Guidelines are used in court to determine the propriety of caring for children and asymptomatic patients, providing wellness care, limiting diagnostic tests to subluxations, and many other crucial factors.

In fact, the insurance company's preference for one set of guidelines over the other can be a determining factor in a doctor's choice of malpractice policies since those guidelines are an essential part of the malpractice litigation process.

According to medical doctor-turned-attorney Armand Leone, Jr., "Courts are increasingly allowing the use of practice guidelines in medical malpractice litigation. Attorneys are using guidelines to assess the validity of potential malpractice cases and to facilitate out-of-court settlements. Insurers are utilizing guidelines to determine payment." ("Guidelines Useful in Malpractice Cases," New Jersey Law Journal, February 6, 1995.)

Therefore, a doctor who practices chiropractic medicine and uses a variety of medical tools to diagnose and treat patients would probably be aligned with the Mercy document and might be better served by having an insurance company that promotes that set of guidelines.

Such a company would be more likely to have at its disposal expert witnesses who support those guidelines and could argue in the doctor's interest.

On the other hand, doctors who practice subluxation-based chiropractic might be at a grave disadvantage with a company that supports the Mercy document. Instead, such practitioners would be best served by a company that supports the CCP Guidelines and can provide expert testimony and other assistance in defending the doctors who focus on the detection and correction of vertebral subluxation.

Insurance companies don't normally like to state their position on various guidelines, for fear of alienating a portion of the profession. However, there is no denying that each one has, though action or statements, shown itself to be in one camp or the other.

Some, like NCMIC or OUM, were early supporters of the Mercy guidelines, contributing substantial amounts of money to develop and distribute the document. In addition, leaders of these companies have publicly gone on record as promoting the Mercy guidelines and have even marketed seminars in them.

Since the Mercy document has been soundly rejected by chiropractors and chiropractic organizations throughout the world, support from insurance companies has been less visible and several companies have denied using it as their underwriting criteria.

Still, their past support, and their unwillingness to openly reject the Mercy Guideline, make it awkward for them to be put in the position of refuting the document in court.

At this time, only one company -- Chiropractic Benefit Services (CBS) -- has openly supported the CCP Guidelines, staunchly promoting it and helping to fund its distribution.

CBS feels the CCP Guidelines are the only chiropractic guidelines that strongly validate subluxation-based chiropractic. It has been effective in court in defending the right of doctors to focus exclusively on the correction of subluxation.

Although malpractice insurance companies will ensure all licensed D.C.s, regardless of their affiliation with one camp or the other, doctors can no doubt expect a more vigorous representation if they choose a company which supports their chosen 'type' of chiropractic.