The claimant was involved in an automobile accident in July 2021 and sought benefits pursuant to the SABS. The claimant submitted an OCF-18 proposing various s. 25 CAT assessments. The plan also sought funding for interviews with treatment providers and individuals who had knowledge of the claimant pre and post accident ($1,000.00), WPI psychological ratings needed for Criterion 7 ($2,000.00), and CAT file review and imaging review ($2,000.00), which the insurer denied. The claimant argued that the interview and file review components of the disputed plan would enable assessors to contextualize the claimant’s presentation, consider the progression of impairments, and cross-reference historical medical evidence with the claimant’s daily life. The claimant further argued that a denial that severs these foundational components undermines the integrity of the assessment process and reflects an arbitrary and piecemeal approach to adjudication. The Tribunal was of the view that because the file review is so necessary, it should be treated as part of the assessment’s process. It is duplicative, and therefore unreasonable, to bill for a file review in addition to a $2,000 assessment. The claimant made general submissions but did not direct the Tribunal to evidence to support the reasonableness and necessity of the interview component of the disputed OCF-18. The Tribunal found that a separate assessment for Criterion 7, which would be evaluated using the Guides 6th edition and an assessment for Criterion 8, which would be evaluated using the Guides 4th edition, would not be duplicative and that each assessment speaks to different clinical evaluations and therefore reasonable and necessary.
