P.K. v. Coseco Insurance Company (19-004126)

The claimant sought entitlement to various medical benefits for physiotherapy services, representing the balances owing on several treatment plans approved by the insurer and invoiced some months after the services were incurred by the claimant. The insurer did not dispute the reasonableness and necessity of the disputed benefits, but rather that payment of the benefits would exceed the $50,000 policy cap in the SABS. Adjudicator Farlam held that the claimant was not entitled to the disputed treatment plans, noting that the $50,000 monetary limit is one prescribed by law. While there are exceptions for optional benefits and catastrophic impairment, neither exception applied in this matter.