The claimant filed a request for reconsideration of Adjudicator Norris’ decision that found the claimant was entitled to a physiotherapy treatment plan but not entitled to a chiropractic treatment plan, nor a second physiotherapy treatment plan. The claimant submitted that Adjudicator Norris made a significant error of law and that he misinterpreted section 38(11). Adjudicator Norris found that the insurer’s notice in response to the physiotherapy plan that was found to be not reasonable and necessary, failed to comply with section 38(8). As a result of that failure, Adjudicator Norris determined that the claimant was entitled to the goods and services related to that treatment plan which were incurred during the period starting on the 11th business day following the submission of the treatment plan. However, there was no evidence to show that the claimant incurred any goods or services on the 11th business day or any day thereafter. Thus, the claimant was not entitled to any payment. The claimant submitted that the insurer’s failure to comply with section 38(11) entitled him to all the goods and services described in the treatment plan that related to the period starting on the 11th business day, regardless of whether the goods and services were incurred. Further, the claimant relied on the principle set out in Rizzo and Rizzo Shoes Ltd. and submitted that the phrase “described” in section 38(11) did not require the claimant to incur the goods and services. The claimant argued that different language would have been used had there been a requirement to incur the goods and services. Adjudicator Norris opined that section 38(11)(2) served as an exception to the reasonable and necessary test, but only to compel timely responses from insurers. Moreover, section 38(15) directs insurers to make timely payment to service providers for the goods and services the insurer previously agreed to pay for. The latter part of the section addresses incurred goods and services the insurer was obligated to pay for as a result of an untimely or insufficient response. Lastly, Adjudicator Norris found that the claimant’s position led to an absurd result. The result was that a potential service provider receives a financial windfall from an insurer’s failure to comply with the time constraints of the Schedule, and the insured would be left without treatment. In conclusion, Adjudicator Norris found no error of law in the decision and dismissed the claimant’s reconsideration request.
Menu