The claimant submitted that the insurer failed to comply with its obligations under section 38(8) regarding its notices that denied the disputed treatment plans. Adjudicator Lake found that the insurer’s response letter failed to provide any specific details about the claimant’s condition that formed the basis of its decision, and failed to provide an explanation for why the insurer concluded that the treatment plan was not reasonable and necessary. Adjudicator Lake stated that simply attaching an IE report to an Explanation of Benefits letter with a bare statement that the treatment plan was not reasonable and necessary was not sufficient enough to allow an unsophisticated person to make an informed decision to either accept or dispute the decision at issue and certainly does not serve the Schedule’s consumer protection goal.
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