FSCO Director's Delegate Evans has upheld an arbitration decision that has found that a treatment and assessment plan is not payable despite a Section 38 deficiency if the OCF-18 is not warranted.
In Sadozai v. State Farm Mutual Automobile Insurance Company, Mr. Sadozai appealed the denial of an in-home assessment by Arbitrator Musson. Counsel for Mr. Sadozai argued that since State Farm had failed to provide a denial within ten business days of receipt of the OCF-18, it should be automatically payable. Arbitrator Musson had indicated that the onus is on the claimant to prove that the medical benefits and costs of examinations in dispute are necessary, which Mr. Sadozai failed to do.
Director's Delegate Evans agreed with Arbitrator Musson, citing the analysis of Arbitrator Wilson in Ying Al Chen and State Farm Mutual Automobile Insurance Company, May 30, 2016. Arbitrator Wilson noted, theSABSis not a lottery for treatment providers where the prize is the deemed approval of a meritless treatment plan. Further, the precondition is that the claimed expenses be 'reasonable and necessary' before an insured can claim indemnity from an insurer.
This decision reinforces the importance of considering the merit of each treatment and assessment plan disputed, despite a Section 38 deficiency.
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