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J.T. v. Cayuga Mutual Insurance Co.(18-006061)

  • April 27, 2020

The claimant sought entitlement to various medical benefits and the cost of an OCF-3. Prior to the hearing, the insurer approved the denied medical benefits, leaving only two issues remaining: a special award, and payment of an OCF-3. The claimant argued that the insurer acted unreasonably by requiring her to attend IEs prior to her MIG removal and that there ample medical evidence provided that proved a non-MIG position. Adjudicator Hans did not grant a special award as the clamant had pre-existing conditions, and the medical information on file did not clearly differentiate between those issues and the accident-related issue. He ruled that it was completely in keeping with SABS and the evidence for the insurer to examine the claimant to determine her MIG status. The OCF-3 was found to be payable even though it was not requested by the insurer as it contained new medical information, including re-entitlement to a NEB.

Full decision here

TGP Analysis

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  • FILED UNDER Medical Benefits, Special Award
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