Claim for case management services denied as applicant demonstrated capacity to independently manage her own rehabilitation.
The applicant, who sustained a catastrophic impairment in a motor vehicle accident, sought payment for case management services (CMS) under the Statutory Accident Benefits Schedule.
The insurer partially denied a 2015 CMS plan based on the Professional Services Guideline limits and fully denied a 2018 CMS plan, arguing the applicant no longer required the services.
The Licence Appeal Tribunal dismissed the appeal, finding the insurer was not liable for amounts exceeding the Guideline limits for the 2015 plan.
For the 2018 plan, the Tribunal preferred the insurer's nursing assessment, which demonstrated the applicant's current capacity to independently manage her treatment and rehabilitation, concluding the CMS was not reasonable and necessary.
OLATOntario Licence Appeal TribunalAug 7, 2019
