The claimant sought entitlement to three treatment plans for chiropractic treatment. Adjudicator Lake found that the claimant was entitled to all three of the treatment plans, plus interest as a result of the insurer’s failure to comply with section 38(8). The claimant cited the decision of T.F. v. Peel Mutual Insurance Company, stating that an insurer’s “”medical and other reasons”” should, at the very least, include specific details about the claimant’s condition forming the basis for the insurer’s decision or, alternatively, identify information about the claimant’s condition that the insurer does not have, but requires. Adjudicator Lake found that the insurer’s denial notices did not comply with its obligations under section 38(8) because they mentioned “”injuries,”” but did not specify which injuries or conditions formed the basis of the decision, and did not include the IE report that it relied upon in correspondence. Further, the insurer highlighted the IE report’s recommendation for an independent exercise program, but failed to address the fact that the proposed treatment plans also included, in part, an exercise program. Finally, Adjudicator Lake stated that the insurer did not sufficiently identify the information that it still required from the claimant.
Menu