Some years ago a director of one of the largest auto insurance carriers, a graduate of our executive M.B.A. program at the University of Hawaii, gave a lecture about successful business practices.

I raised my hand and commented that as a physician on the islands, I didn’t have much good to say about his company, but asked if he was bullish on the stock. He chuckled. “I play softball,” he said. “The lawyers on my team sue my company all the time. It’s an industry.”

He then elaborated. “Insurance companies collect premiums,” he said. “Some of those insured get into accidents and receive health care. Plaintiff and defense attorneys argue about damages, and everyone makes a living.”

Until the late ’90s most people in Hawaii were covered for up to $20,000 of medical costs per person per accident. The state determined that if you had at least $13,500 in health care costs, you likely also had substantial pain and suffering. If the accident was not your fault, a plaintiff’s attorney could sue the other driver’s insurance, on your behalf, for damages. The problem was that awards were relatively high, and certain parties were accused of exaggerating injuries. There were allegations that a subgroup of health providers, particularly chiropractors, as well as a few plaintiff’s attorneys and patients, were abusing the system. Insurance companies often felt obligated to contract independent medical examiners to refute what they thought were errant claims. These were contentious times.

Tort reform during the late ’90s changed the face of the industry. There were winners and losers. Minimum coverage for medical costs per person, per accident, dropped to $10,000. The tort threshold also dropped, to $5,000 from $13,500. Chiropractors, acupuncturists and naturopaths were mandated to charge no more than $75 per visit, and the combined number of visits to these three professions per occurrence are now limited to 30. All other services, including medical visits, physical therapy, massage therapy, medications, diagnostics and procedures, must still simply be “reasonable, appropriate and necessary” and, of course, within the policy limit.

The result has been a trend toward smaller awards. Carriers now tend to have less to lose and only rarely contract independent medical examiners to refute claims. Interest on the part of some in the legal profession has waned, and the number of chiropractors in the state has dropped.

Patients now have more unobstructed access to injury care that includes a broad range of services, a number of which are not available under private insurance. The big downside of the reduced minimum level of medical benefits, particularly in the event of a hospital admission or surgical procedure, is that patients will usually run out of funds. If that happens and the person also has private insurance, that carrier should then assume care, but only for services included in the private policy. Unfortunately, many people do not have private insurance as a fallback. According to one plaintiff’s attorney, “It’s not a good time to be an injured and innocent person in Hawaii. It is a good time to be an insurance carrier.”

People involved in motor vehicle accidents face not only personal injury, but also damage to one of their most valuable possessions and their primary means of transportation. They also face lost work, lost income and, usually, increased stress at home.

Perhaps it is just an “industry,” as the director says. Carriers, attorneys and providers do make a living in consideration for their services. Certainly there are those who will try to abuse it. Still, I recall feeling that his comment seemed too cavalier. For those involved in a substantial accident, that pain and suffering is real.