2 total
Application for accident benefits dismissed; treatment plans found duplicative and lacking medical evidence.
The applicant sought payment for occupational therapy and rehabilitation therapy treatment plans following a 2014 motor vehicle accident.
The Licence Appeal Tribunal dismissed the application, finding the occupational therapy plan was duplicative of a previously approved plan that had not been exhausted.
The rehabilitation therapy plan was denied due to a lack of compelling medical evidence demonstrating it was reasonable and necessary.
The Tribunal also found the insurer's denial notices complied with s. 38(8) of the Schedule.
Claims for interest and a special award were dismissed.
Insurer ordered to pay $2,000 medical benefit due to deficient denial notice under SABS.
The applicant sought a medical benefit of $2,000 for an attendant care assessment following a motor vehicle accident.
The insurer denied the treatment plan on the basis that the applicant's injuries fell within the Minor Injury Guideline (MIG).
The Tribunal found that the insurer's denial notice was deficient under section 38(8) of the Schedule because it misstated the insurer's examination report and failed to reassess the treatment plan after the applicant was removed from the MIG.
Consequently, under section 38(11), the insurer was liable to pay for the disputed benefit.
The Tribunal ordered the insurer to pay the $2,000 benefit plus interest.
