A preliminary issue hearing was held to address whether the claimant was entitled to payment of NEBs until the substantive hearing based on the insurer’s failure to comply with section 36 of the SABS. Adjudicator Farlam found that the claimant was not entitled to the payment of NEBs until the substantive hearing and that the claimant failed to prove that the insurer did not comply with the SABs. A denial letter was sent indicating that the insurer did not have sufficient medical information to support the claimant’s entitlement to NEBS and that the benefit would not be payable until the receipt of additional information, which was requested under section 33. The claimant failed to comply with the insurer’s request. The claimant argued that the letter was not SABs compliant as it failed to reference the submitted OCF3. Adjudicator Farlam highlighted that there is no requirement that an OCF3 be mentioned in a denial letter. The claimant further argued that she had requested the additional records and ought to have been paid NEBs in the meantime. Adjudicator Farlam disagreed, finding that the requirement is for a claimant to provide records to the insurer, not merely request them.
