S.B. v. State Farm Insurance (17-003290)

The claimant sought entitlement to a number of medical benefits. On review, Adjudicator Christopher Ferguson determined that a number of treatment sought exceeded the monetary value claimed in the treatment plans, as well as in the Professional Service Guideline. Where the claims exceeded the PSGs, the treatment was not awarded. However, the remaining treatment plans, on review of the medical evidence were deemed reasonable and necessary.

Applicant v. State Farm Insurance Company (16-002858)

The claimant sought entitlement to three additional assessments related to a catastrophic impairment determination. The insurer denied them as being duplicative and unreasonable. Adjudicator Johal held that the in order to be payable, the proposed catastrophic impairment assessment had to be reasonable and necessary. Each proposed assessment was to be examined on that standard. Adjudicator Johal held that two of the proposed assessments were reasonable and necessary, but that no evidence was provided supporting the third assessment. The adjudicator also held that a maximum of $2,000 was to be paid for each proposed assessment. She denied a special award, stating that the insurer had based its denial on two paper review IEs and that it was not unreasonable for the insurer to do so.