Insurer ordered to pay $10,000 special award for unreasonably delaying approval of necessary dental implants.
The applicant was severely injured in a motorcycle accident, resulting in the loss of several teeth.
He sought coverage for dental implants, but the insurer refused, offering only to pay for a removable denture.
The insurer maintained its refusal until the eve of the arbitration hearing, despite receiving multiple reports from the applicant's treating dentists and its own retained experts indicating that implants were reasonable and necessary.
The arbitrator found that the insurer unreasonably withheld the dental benefits and violated the 'pay pending dispute' provision of the Statutory Accident Benefits Schedule.
The arbitrator ordered the insurer to pay the $25,000 cost of the implants, awarded a $10,000 special award for the unreasonable delay, and ordered the payment of interest on the future expenses from the mid-point of the anticipated treatment period.
OFSCDRSOntario Financial Services Commission - Dispute Resolution ServicesJul 17, 1995
