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S.P. v. Gore Mutual Insurance Company (17-003686)

  • January 21, 2019

The claimant applied for accident benefits one year after an accident. She sought entitlement to a treatment plan for physical therapy. The insurer denied the claim and argued that the claimant was barred from pursuing accident benefits due to her late application. Adjudicator Msosa held that the claimant provided a reasonable explanation for the late application. The claimant had divorced from her husband and she did not receive the claims materials sent to her by the insurer. She also stated that she believed that her symptoms would resolve, but when they didn’t, she sought physical therapy. Adjudicator Msosa also found the physical therapy to be reasonable and necessary for the claimant’s ongoing pain.

Full decision here

TGP Analysis

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  • FILED UNDER Medical Benefits, Late Application
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