Dr. J. VanDeursen

The appellant insurer appealed an arbitrator's decision granting a special award to the respondent for unreasonably withholding payments for rehabilitation support worker services and private school tuition.

The Director's Delegate confirmed the appeal decision, finding that there was an adequate evidentiary foundation to support the arbitrator's finding that the insurer acted unreasonably.

The insurer had failed to consider new information, including a DVD with statements from the respondent's rehabilitation team, and relied on overlapping and preliminary assessments to deny benefits.

The insurer appealed an arbitrator's decision awarding the insured, a minor who sustained a catastrophic brain injury, private school tuition as a rehabilitation benefit and a $28,000 special award for unreasonably withholding benefits.

The Director's Delegate upheld the tuition award, finding no error in the arbitrator's conclusion that the expense was reasonable, necessary, and 'incurred' under the Schedule despite not being paid upfront.

The Delegate also upheld the entitlement to a special award, noting the insurer unreasonably relied on preliminary and flawed expert reports to deny benefits.

However, the Delegate set aside the quantum of the special award and remitted it to arbitration, finding the arbitrator failed to provide sufficient reasons explaining how the $28,000 figure was calculated.

The applicant, a minor who sustained a catastrophic brain injury in a motor vehicle accident, sought statutory accident benefits for private school tuition and rehabilitation support worker services.

The insurer denied the claims based on its own medical examinations.

The arbitrator found the insurer's denials unreasonable, preferring the evidence of the applicant's treating team that the services were necessary for his social reintegration and cognitive development.

The arbitrator awarded the claimed benefits, interest, and a $28,000 special award against the insurer for unreasonably withholding payments.