The claimant disputed entitlement to a chronic pain assessment and a psychological assessment. The claimant argued that in denying these plans, the insurer did not specify a medical basis for the denial or request further medical documentation from the claimant. The claimant further contended that the insurer failed to provide a medical ground for maintaining the MIG designation of the claimant, and that, regardless of whether the proposed treatment plans were deemed reasonable and necessary, sections 38(8) and 38(11) of the SABS preclude the insurer from maintaining such designation. The insurer argued that, contrary to section 33.1(1) of the SABS, the claimant failed to provide her family doctor’s CNRs in support of her proposed OCF-18s as requested until approximately two years after the accident. Furthermore, the insurer submitted that sections 38(8) and 38(11) of the SABS were fulfilled by its request for the CNRs. Adjudicator Roswell preferred the insurer’s argument, holding that insurers have the right to reject treatment and assessment plans during the time when a claimant is eligible for goods and services under the MIG where the claimant submits requested medical information past the deadline specified in the SABS and does not exhaust the MIG. A medical basis is only a prerequisite for an insurer’s denial of proposed OCF-18s where the relevant medical records are produced by the claimant in the time frame prescribed by 33.1(1) of the SABS, which the claimant failed to do. Adjudicator Roswell also noted that, under s.38(6) of the SABS, the insurer’s decision to refuse a treatment and assessment plan under s. 38(5) is final and cannot be reviewed. Therefore, Adjudicator Roswell found that the insurer’s denial notice was sufficient. In addition, Adjudicator Roswell held that the claimant’s pre-existing psychological conditions, evidenced in the CNRs, constituted evidence sufficient to remove the claimant from the MIG.
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