The claimant sought entitlement to medical benefits and interest. The claimant had earlier been accepted as catastrophically impaired. The insurer disputed the overall costs of assessments, which it had partially approved. Vice Chair Boyce concluded the claimant was not entitled to any of the partially denied assessments. The claimant claimed entitlement to the assessor’s denied travel expenses for an in-home assessment. The insurer argued that pursuant to s.25(4) it was not liable to pay more than $2,000 for fees and expenses on any one assessment and the claimant bore the burden to prove the cost was reasonable and necessary. The claimant argued that she lived in a rural area, which justified the travel cost. Vice Chair Boyce agreed that the insurer was not obligated to pay for the provider’s travel expenses in addition to the $2,000 cap under s.25(5)(a), which was already included in the capped fee amount. No evidence was provided to show the provider was unwilling to travel if her travel expenses were not paid. The claimant also claimed entitlement to full payment for a neuropsychological CAT assessment. The insurer denied payment of the clinical file review claim in the amount of $2,000 based on s.25(5)(a) limit that includes a file review. The claimant submitted that the assessment had two components: psychological and neurological. The neurological assessment proposed was two separate assessments conducted by one assessor. Vice Chair Boyce agreed that the individual assessments were capped at $2,000 and the cost of the neuropsychological assessment at $5,500 more than the other assessments was not reasonable or necessary. The Tribunal had consistently found file reviews necessarily formed part of conducting an assessment and was not separate from the $2,000 payment. The claimant further claimed a remaining $2,000 for a neuropsychological assessment. The insurer again denied payment on the basis of s.25(5)(a) and argued that the claimant had attempted to skirt the s.25(5)(a) fee limit for assessments by intentionally separating the assessments into psychological and neuro-cognitive assessments to get two separate $2,000 payments. The OCF-18 provided the same descriptions and codes on the OCF-18 for both assessments. Vice Chair Boyce found the claimant had not demonstrated the reasonableness of the unapproved portion of the OCF-18.
