2 total
Reconsideration dismissed; an OCF-18 alone is not compelling evidence and adjusters may issue valid denials.
The applicant requested a reconsideration of a Licence Appeal Tribunal decision that denied her claims for Income Replacement Benefits, two treatment plans (OCF-18s) for chiropractic services, interest, and an award.
The applicant argued that the Tribunal erred in law by finding that an OCF-18 alone is not compelling evidence and that a denial issued by a non-health practitioner (an adjuster) could be compliant with s. 38(8) of the Statutory Accident Benefits Schedule.
The adjudicator dismissed the reconsideration request, holding that an OCF-18 is a form used to apply for treatment rather than compelling medical evidence on its own, and that s. 38(8) requires the insurer—not necessarily a health practitioner—to provide the medical and other reasons for denying a treatment plan.
As no error of law or fact was established, the original decision was upheld.
Application for income replacement benefits and chiropractic treatment plans dismissed for lack of evidence.
The applicant sought statutory accident benefits following a motor vehicle accident, including income replacement benefits (IRBs) and two treatment plans for chiropractic services.
The Tribunal found that the applicant failed to meet her burden of proof to establish entitlement to a higher quantum of pre-104 IRBs or entitlement to post-104 IRBs, as she provided no substantive submissions on these points.
The Tribunal also rejected the applicant's arguments that the respondent's notices were non-compliant with the Schedule, finding that the respondent provided adequate medical and other reasons for its denials under s. 38(8) and properly requested an insurer's examination under s. 37(1).
As the applicant failed to establish that the proposed treatments were reasonable and necessary, the application was dismissed.
