The applicant sought payment for an occupational therapy assessment following a motor vehicle accident.
The insurer denied the treatment plan, arguing it was for attendant care beyond the 104-week limit.
The Tribunal found the insurer's denial failed to comply with s. 38(8) of the Schedule because it did not address the actual benefit claimed (an OT assessment) and lacked proper medical reasons.
Consequently, the applicant was entitled to the cost of the assessment if incurred.
The Tribunal dismissed the claim for an award under s. 10 of Regulation 664, finding the insurer's defective denial was a mistake rather than excessive or imprudent conduct.
