Category: Medical Benefits

The claimant sought entitlement to a chronic pain assessment. The insurer denied the assessment. Adjudicator Chris Sewrattan referenced a previous decision in the same matter where it was held that it was reasonably possible the claimant suffered from chronic pain syndrome. Based on the medical evidence, Adjudicator Sewrattan reasoned that a chronic pain assessment was the only way to determine if the claimant indeed suffered from chronic pain and whether further treatment was needed. The assessment was deemed payable with interest in accordance with section 51 of the SABS.

The claimant sought entitlement to a chronic pain assessment. The insurer denied the assessment. Adjudicator Chris Sewrattan referenced a previous decision in the same matter where it was held that it was reasonably possible the claimant suffered from chronic pain syndrome. Based on the medical evidence, Adjudicator Sewrattan reasoned that a chronic pain assessment was the only way to determine if the claimant indeed suffered from chronic pain and whether further treatment was needed. The assessment was deemed payable with interest in accordance with section 51 of the SABS.

The claimant sought entitlement to one treatment plan for chiropractic treatment. Adjudicator Treksler concluded that although the claimant had been diagnosed with whiplash as a direct result of the accident, she had not provided any objective medical opinion to support that the chiropractic treatment would improve or resolve her injuries. The claimant was not entitled to payment of the treatment plan, as she had not shown that the treatment plan was reasonable and necessary.

The claimant sought entitlement to a number of medical treatment plans. The insurer denied the plans based on IE reports. Adjudicator Brian Norris reviewed the medical evidence and determined that the treatment plans were not reasonable and necessary. The application was dismissed.

The claimant and the insurer disagreed on the amount payable to a case manager. The claimant sought $150 per hour; the insurer argued that the Professional Services Guideline capped the hourly rate at $89.07. Adjudicator Maedel concluded that the PSGs applied to the services provided to the claimant, and that $89.07 was the maximum payable. Central to the decision was the determination that the claimant’s case managers were “qualified case managers” despite also being Registered Social Workers. Although the case managers had such professional designations, the services provided were in the nature of case management.