The claimant sought to be removed from the MIG and sought entitlement to three treatment plans and the cost of an orthopaedic assessment. Adjudicator Hines concluded that the claimant sustained a minor injury, but was entitled to payment for the disputed treatment plans if they had been incurred prior to receiving proper notice from the insurer denying the benefits. Adjudicator Hines found that the insurer failed to provide adequate medical and other reasons for denying the treatment plans because the insurer’s denial of the treatment plans failed to refer to the claimant’s medical condition. Further, the notices did not state that the MIG applied, which is mandatory under section 38(9). In addition, the insurer failed to reference any medical records that it had received or to request additional medical records. Finally, Adjudicator Hines agreed with the arbitrator’s interpretation in Ferawana v. State Farm, that whether the treatment plans are reasonable and necessary is irrelevant to whether the mandatory payment consequence of section 38(11)(2) applies. Adjudicator Hines also agreed that nothing in the Schedule relieves an insurer of its liability from the mandatory payment provision on the basis that a treatment plan is not reasonable and necessary.
Menu