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K.H. v. Gore Mutual Insurance (18-009689)

  • August 12, 2020

The claimant filed a Request for Reconsideration arising out of a decision in which the Tribunal found the claimant entitled to medical benefits proposed in a treatment plan, but not entitled to a special award. The claimant argued that Adjudicator Norris erred in law or fact when considering her entitlement to a special award. Adjudicator Norris first considered the insurer’s inaction following the submission of the disputed treatment plan. Adjudicator Norris found that the insurer’s inaction was reasonable, and it was not unreasonable to rely on the opinions in an IE report that were provided by a regulated healthcare professional. Second, the circumstances surrounding the prognosis in the IE report were considered in the decision. Adjudicator Norris held that there was no error in law in how the issue of the prognosis in the IE report was analyzed. In conclusion, Adjudicator Norris agreed with the insurer and found that the claimant failed to prove that a significant error in law or fact occurred.

Full decision here

TGP Analysis

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  • FILED UNDER Special Award, Reconsideration
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