Mark Rowe

The appellant was injured in a motor vehicle accident and sought payment for two kinesiologist reports prepared by an assessment facility.

The insurer refused payment on the basis that the reports duplicated its own assessments and were not obtained for the purpose of the regulation.

The arbitrator dismissed the claim, finding no evidence that the referral was reasonable or that the reports were useful for the appellant's rehabilitation.

The arbitrator also ordered the appellant to pay the insurer's arbitration expenses.

On appeal, the Director's Delegate upheld the arbitrator's decisions, confirming that the insurer is not required to pay for stand-alone assessments initiated by service providers without reference to treatment needs, and finding no error in the expenses order.

The appellant appealed a preliminary arbitration order concerning the scope of the issue to be arbitrated.

The insurer had paid the base fee for an assessment but refused to pay a premium fee adjustment for travel time.

At arbitration, the insurer argued the appellant must prove the reasonableness of the entire account, which the arbitrator accepted.

On appeal, the Director's Delegate held that the insurer's prior payment and conduct put the reasonableness of the assessment itself beyond dispute.

The arbitrator exceeded her jurisdiction by expanding the issue.

The appeal was allowed and the matter remitted to determine only the entitlement to the premium fee adjustment.

The appellant appealed an arbitrator's decision denying payment for an in-home assessment following a motor vehicle accident.

The appellant argued that the insurer should be restricted to the reasons for denial set out in its initial notice, and alternatively, that there was sufficient evidence the assessment was for the purpose of the Statutory Accident Benefits Schedule.

The Director's Delegate dismissed the appeal, holding that an insurer is not strictly limited to its initial reasons for denial, provided there is fair disclosure and no undue prejudice.

Furthermore, the Director's Delegate upheld the arbitrator's finding that the appellant failed to provide sufficient evidence demonstrating that the assessment report was intended to be used for a treatment plan or other rehabilitation purpose under the Regulation.