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

  • December 9, 2019

The claimant sought entitlement to a treatment plan that included physiotherapy, massage therapy, and swim passes, interest on the payment of overdue benefits, and a special award. Adjudicator Norris found that the claimant was entitled to the disputed treatment because it was reasonable and necessary to address the claimant’s ongoing pain and functional limitations. The claimant was diagnosed with chronic pain syndrome and there was evidence that her ongoing pain symptoms responded well to treatment. However, Adjudicator Norris did not find that the insurer’s conduct warranted the claimant’s entitlement to a special award: the claimant argued that the respondent acted unreasonably in failing to redact the assessor’s prognosis from the insurer’s examination report when prognosis was an issue the parties agreed to omit from the insurer’s examination requisition prior to scheduling the assessment; however, Adjudicator Norris found no obligation, legislative or otherwise, for the insurer to redact/revise the report. The claimant was awarded interest on the payment of the disputed treatment plan.

Full decision here

TGP Analysis

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  • FILED UNDER Medical Benefits
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