D.N. v. Aviva Insurance Company (17-004104)

The claimant sought entitlement to two assessments, and argued that the treatment plans were denied more than 10 days after submission. The insurer argued that the claimant failed to attend IEs. Adjudicator Norris agreed with the claimant that the treatment plans had been denied more than 10 days after submission due to the deeming provision at section 64(18) of the SABS relating to mail. However, the adjudicator also concluded that the insurer sent a proper denial before the proposed goods and services were completed, and they were therefore not payable. He also found that the claimant failed to attend a scheduled IE, and therefore could not dispute his entitlement to one of the proposed assessments. The other assessments was denied as being not reasonable and necessary.