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P.K. v. Cumis General Insurance (16-001809)

  • March 28, 2017

The claimant sought entitlement to eight treatment plans, including prescription medication. Adjudicator Sewrattan found five of the treatment plans were not payable as the treatment was incurred before the submission of treatment plans. When interpreting section 38(2), it was noted that there was no “reasonable excuse” exception; therefore, if the claimant did not meet any of the expressed exceptions to incurring treatment before the submission of a treatment plan, the LAT cannot exercise any discretion to find treatment payable. The prescription medication, however, was found payable by operation of section 32(2)(c)(i). Because the accident necessitated the prescription medication, and the medication was reasonable and provided by a regulated professional, the medication was found payable. The remaining treatment plans, with one exception, were deemed reasonable and payable.

Full decision here

TGP Analysis

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  • FILED UNDER Medical Benefits
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