The claimant sought reconsideration of the Tribunal’s decision that she was barred from seeking entitlement to two treatment plans, arguing that the insurer’s denials did not provider the requisite medical reasons. Executive Chair Lamoureux agreed with the claimant and overturned the decision. She held that the insurer’s medical reasons had to engage the specific details about the claimant’s condition, and should be adequate enough to allow an unsophisticated person to understand them and make an informed decision. She reasoned that the insurer’s denials in this case failed to cite the specific documentation upon which the insurer was relying in denying the proposed benefits.
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