Applicant partially entitled to accident benefits due to insurer's failure to provide clear medical denials.
The applicant was injured in a motor vehicle accident and sought statutory accident benefits for a chiropractic treatment plan, a psychological assessment, and a psychological treatment plan.
The respondent partially denied funding for these plans.
The Tribunal found that the chiropractic treatment plan was not reasonable and necessary, but the applicant was entitled to some incurred expenses because the respondent failed to provide a valid medical reason for the denial within the required timeframe.
The Tribunal also found the applicant was entitled to the unpaid balance of the psychological assessment because the respondent's denial was not clear and unequivocal.
The balance of the psychological treatment plan was denied as it was not reasonable and necessary, and the psychotherapist was not entitled to the same hourly rate as a psychologist.
Interest was awarded on the overdue payments.
OLATOntario Licence Appeal TribunalJan 24, 2020
