Reasons for Rejecting Treatment Plan Need Not Be Detailed

In Pereira v. Coseco Insurance, released last month, an Ontario Superior Court judge stayed the insured’s lawsuit pending her attended for a DAC assessment. The reasons for judgment can be viewed at

The claim related to med-rehab benefits. The insurer had refused to pay for the claimant’s treatment plan and exercised its right to have the insured undergo a DAC assessment.

The insured sued and contended that she was not obliged to submit to a DAC assessment because the insurer’s refusal to pay for the treatment plan had been lacking in specifics. (It had said only that “we are unable to determine if the treatment plan is reasonable and necessary”.)

Justice Cameron ordered the insured’s action stayed until she had attended for a DAC examination and the claim had been mediated. Unfortunately, while he appears to have accepted the insurer’s argument, that its notice was adequate, he did not discuss just what information an insurer is required to provide when rejecting a treatment plan.

Justice Cameron referred to s. 38(12) of the SABS, which obliges an insurer to “notify the insured of (i) its reasons for declining to pay for a part or all of the treatment plan”. His ruling in favour of the insurer implies (in our view) that he considered Coseco’s reasons (quoted above) for rejecting the plan to be adequate.

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