Applicant v. Aviva Insurance Company (17-001922)

The claimant sought entitlement to a number of medical benefits. The insurer asserted that the treatment plans were not reasonable and necessary and that one plan was partially approved in accordance with the Professional Service Guidelines. Adjudicator Therese Reilly, on review of the evidence, found none of the claimant’s claims payable. The PSGs were accepted as the appropriate cap on services and therefore the partial approval by the insurer was correct. The remaining claims were not substantiated by the claimant and deemed not reasonable and necessary.