The claimant applied to the LAT seeking entitlement to the benefits proposed in three treatment plans. Adjudicator Norris found that the proposed chiropractic treatment plan was not reasonable and necessary, but as the insurer’s initial denial letter was non-compliant with s. 38 “medical and other all reasons” requirements, the claimant was entitled to payment for the goods and services incurred during the period from the 11th business day following receipt of the treatment plan to the date a compliant notice was provided. The claimant was entitled to the balance of a psychological assessment because the partial approval letter was not clear and unequivocal. The claimant was not entitled to the balance of a psychological treatment plan because the proposed services (communication with other treatment providers, treatment planning, and preparation of a progress report) were found to be not reasonable and necessary.
Menu