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Y.L.C. v. Gore Mutual Insurance Company (18-010499)

  • February 3, 2020

The claimant disputed his entitlement to chiropractic treatment and income replacement benefits. The insurer denied the proposed chiropractic treatment based on a physiatry IE report which found that further facility-based treatment would not be helpful. Vice Chair Lester nevertheless determined that the disputed treatment plan was reasonable and necessary, given the records from the treating facility which showed ongoing improvements in the claimant’s range of motion and the fact that the claimant’s family physician had recently referred him to a chronic pain clinic for the same types of issues he complained of to the physiatry assessor. Vice Chair Lester concluded that she did not have jurisdiction to deal with the merits of the IRB claim, as the insurer had not denied entitlement to IRBs but rather suspended entitlement for failure to comply with a section 33 request for production of financial documentation.

Full decision here

TGP Analysis

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  • FILED UNDER Income Replacement Benefits, Medical Benefits, Section 33
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