The claimant applied to the LAT seeking entitlement to various medical benefits, including further physical treatment and assessments. Section 38(8) of the SABs provide that an insurer shall respond to a treatment plan within 10 business of receipt and must provide the claimant correspondence outlining all medical and all other reasons for any denial. As guidance, the LAT explained that medical and other reasons should at the very least include specific details about a claimant conditions which form the basis for the insurer’s decision. In this case the claimant submitted a treatment plan for an assessment of function to identify barrier to recovery. The insurer denied two assessments citing the lack of medical evidence and the report of its IE assessor who agreed with the findings of an emergency physician that the claimant sustained a left sprain and lumbosacral strain in the accident. Adjudicator Kaur found the insurer’s denial to be insufficient. The insurer failed to provide adequate medical reasons explaining why the assessments were denied. Stating that there was “insufficient medical documentation” was not a medical reason, nor was simply repeating one finding of the IE assessor. The insurer’s denial did not provide an explanation that would allow the claimant to understand why the proposed assessments were not reasonably and necessary in light of the two cited reasons. One treatment plan for physical therapy was also awarded as being reasonable and necessary. The remaining proposed medical treatment was denied by the Tribunal as not reasonable and necessary.
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