The respondent insurer requested a reconsideration of a Licence Appeal Tribunal decision that awarded the applicant the cost of an orthopaedic assessment.
The Tribunal originally found that the insurer failed to provide a 'clear and unequivocal' denial of the treatment plan and that the insurer requested an insurer's examination more often than reasonably necessary.
On reconsideration, the Vice-Chair held that the Tribunal made significant errors of law and fact, noting that section 38(8) of the Schedule does not require a 'clear and unequivocal' denial and that the insurer's notice was compliant.
The Vice-Chair also found a breach of procedural fairness because the insurer was not given an opportunity to make submissions on the frequency of examinations.
Upon reviewing the merits, the Vice-Chair concluded the applicant failed to prove the orthopaedic assessment was reasonable and necessary, and varied the decision to dismiss the application for the assessment.