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A.H. v. Belair Direct Insurance Company (16-001063)

  • August 8, 2017

The claimant sought entitlement to a number of treatment plans and attendant care benefits. Adjudicator Lori Marzinotto noted that some of the treatment plans sought were not submitted as evidence, nor specifically addressed in the claimant’s submissions; those plans were denied. Other treatment plans sought mileage beyond the Professional Service Guidelines. Adjudicator Marzinotto highlighted no evidence was tendered to support exceeding the PSG; those previously partially approved plans were accordingly maintained. With respect to attendant care benefits, Adjudicator Marzinotto noted no evidence was provided to satisfy economic loss for much of the period claimed; therefore attendant care benefits were not payable for that time. However, the claimant was entitled to attendant care benefits from February 2016 onwards, as the evidence supported it was reasonable and necessary, and incurred, but that the rate charged by the service provider was in excess of the FSCO Guidelines.

Full decision here

TGP Analysis

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  • FILED UNDER Medical Benefits, Attendant Care Benefits, Incurred Expense
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