Category: Medical Benefits

The claimant sought entitlement to the cost of a psychological assessment and a special award. Adjudicator McQuaid found that the assessment was reasonable and necessary, as the evidence from the ongoing adjustment of the claim supported the need for a psychological assessment. The result of assessments and examinations by four different doctors was a recommendation for psychotherapy treatment. Adjudicator McQuaid found the cost of the examination to be payable but did not grant a special award, finding the insurer’s denial of the cost of the examination was not per se frivolous and vexatious conduct.

The claimant sought entitlement to a rehabilitation treatment plan and interest on the payment of overdue benefits. Adjudicator Grant found that the claimant did not demonstrate that the rehabilitation benefits in dispute for personal training and a gym membership were reasonable and necessary. The treatment plan was contradicted by the claimant’s self-reporting that she had already received education about stretching and strengthening, as well as Dr. Kleinman’s report on the extent of the claimant’s injuries and recommended treatment. The treatment plan was found not payable.

The claimant sought entitlement to medical benefits proposed in two psychological treatment plans. Adjudicator Grant found that the treatment plans were not reasonable and necessary, based on the claimant’s self-reporting and the reports of section 44 assessors. The claimant had acknowledged that he had not experienced any significant disruption, and he denied a desire to participate in psychotherapy counselling. Adjudicator Grant also noted that if the claimant required further psychological treatment, he still had approximately $3,879.00 of approved and not incurred funding available for treatment.

The claimant disputed entitlement to a partially approved OCF-18 for psychological services in the amount of $3,591.87. The insurer paid $2,444.15 of the OCF-18 based upon the Professional Services Guideline for psychological services. Adjudicator Norris noted that the insurer was correct in its payment of the services within the PSG. He commented that the $224.42 per one hour session requested was not appropriate or in accordance with the PSG, while the $149.61 paid by the insurer was. The claimant also argued that the insurer was non-compliant with section 38 for delivering a late response which was “overly generic.” Adjudicator Norris agreed, noting that the denial letter was late and did not provide specific medical or other reasons for the denial. He awarded entitlement to the goods and services incurred during the period of non-compliance, staring on the 11th business day up to the day when the insurer provided a compliant notice.