Viera v. Aviva General Insurance (19-007227)

The claimant sought entitlement to a chronic pain assessment, and argued that the insurer’s denial did not comply with section 38(8). Adjudicator Lake agreed that the insurer’s denial did not comply with section 38(8), as none of the denials included any specific details about the claimant’s condition forming the basis of the insurer’s decision and only generally referred to the claimant’s injuries without any details or explanation. There was also no medical reason for the denial. The final denial contained a number of grammatical errors that made it unclear to an unsophisticated person, nor did it stated that the proposed assessment was not reasonable and necessary. The special award claim was dismissed. The adjudicator held that the failure to comply with section 38(8) did not meet the burden for a special award. The insurer simply misapplied the SABS.