The claimant sought entitlement to two treatment plans, including massage therapy and a chronic pain assessment. Adjudicator Lake found that the claimant was entitled to a portion of the remaining amount for the massage therapy, but was not entitled to the chronic pain assessment. The claimant submitted that the insurer failed to comply with its obligations under section 38(8). Adjudicator Lake stated that failing to provide a compliant denial notice within 10 business days after receipt of the OCF-18 does not render an entire OCF-18 payable. Based on a plain reading of section 38(11)(2), the insurer is liable for payment of the proposed treatment described in the disputed OCF-18 that relates to the period starting on the 11th business day after the day that the insurer received the OCF-18 and ending on the day the insurer gives a notice described in section 38(8). Adjudicator Lake also stated that the amount does not need to be incurred during that time. Further, Adjudicator Lake referenced T.G. v. Peel Mutual Insurance Company, when stating that the insurer did not include sufficient details regarding the claimant’s condition forming the basis for the insurer’s decision. The insurer stated that it was “”unable to determine whether the recommendations on the OCF-18 were reasonable and necessary for the injuries sustained.”” The insurer failed to provide any specific details about the claimant’s condition that formed the basis of its decision and did not, in the alternative, identify information about the claimant’s condition that the insurer did not have, but required. Finally, Adjudicator Lake concluded that medical reasons provided under a separate heading for an IE do not mitigate the requirement of the insurer to provide medical reasons for its denial of the OCF-18 under section 38(8).
