Tran v. Certas Home and Auto Insurance Company (21-004129)

The claimant applied to the LAT for the cost of CAT examinations. The claimant claimed the insurer did not provide adequate medical reasoning in the notice of the denial under section 38(8) of the SABS. The Respondent countered that the notice of denial was adequate based on the request made as there was no medical correlation between the accident and the assessments requested. The adjudicator found that the claimant failed to meet the burden of proof that the notice of denial was invalid. The onus is on the claimant to provide the insurer with a reasonable explanation as to why the assessments are required and how they relate to the accident. Further, the OCF-18 provided no explanation for the assessments other than what assessments were to be performed. The insurer denied the assessment request noting that “the goods and services did not fit with the loss details”. The adjudicator found this statement to be more adequate in describing why the request was denied and found it more meaningful than the reasons provided for the request for the assessments.