Category: Medical Benefits

The insurer approved a portion of the cost of a proposed psychological assessment based on an IE assessor’s view on the appropriate hourly rate to conduct the assessment. The claimant sought the remainder of the proposed amount. Adjudicator Ferguson accepted the insurer’s arguments and held that the remainder of the treatment plan was not payable. He further held that the insurer’s late denial did not result in the automatic payment of the assessment, because a proper denial was provided to the claimant prior to the assessment taking place.

The claimant sought entitlement to a chronic pain program and an orthopaedic assessment. Adjudicator Hans awarded both benefits and wrote that he preferred the evidence from the claimant’s experts over the opinions of the insurer’s experts. In particular, he found the claimant’s experts’ reports to be more thorough in analysis and recommendation. He also did not find the surveillance persuasive as it was taken more than six months after IE assessments.

The claimant sought entitlement to physiotherapy. The insurer denied the treatment plan and asserted the treatment was not reasonable and necessary. Adjudicator Sandeep Johal reviewed the medical evidence and held that the claimant failed to meet the onus of proof. The treatment plan was deemed not reasonable and necessary.

The claimant sought entitlement to a treatment plan for physical therapy. The insurer tendered medical evidence for the proposition that the claimant did not need further facility-based treatment. On review of the medical evidence, Adjudicator Derek Grant noted that while the claimant still experienced effects from the accident, the proposed treatment plan was not reasonable and necessary.