The obligation is generally on the insured person to show or prove that an expense relating to a certain claimed Benefit is reasonable and necessary as the result of an accident.
Section 36 (2) of the SABS provides that an insured proves his claim of entitlement to a Benefit by providing a completed Application for Accident Benefits document (OCF-1 form) and a Disability Certificate (OCF-3 form).
Of course, there is a contractual duty of good faith between an insurer and its insured. The insurer must then make some decision or give some reasonable explanation for any position which the insurer adopts. A breach of this duty is a breach of the insurer’s implied duty of good faith to its insured.
Since the basis for an insured’s claim for a benefit relating to a physical or mental injury or impairment involves a medical opinion of some sort, an insurer has an obligation to medically investigate the reasonableness and necessity of a certain Benefit claimed by its insured, once the insured has shown a prima facie claim to the Benefit by way of an OCF-3.
With regard to the specific benefits of IRBs, NEBs, CGBs, HKBs and HMBs, section 36 (4) of the SABS provides that an insurer shall either pay that claimed Benefit within 10 days of its receipt of the application for it (by receipt of the OCF-1 and OCF-3) or the insurer shall give notice of why it will not pay it, or request an IE (section 44) or request more information (section 33) concerning the Benefit.
Section 36 (6) states that if the insurer breaches section 36 (4), the insurer shall pay the Benefit. That sounds like a deemed entitlement provision, otherwise there would be no meaning attributable to s. 36 (6); a result that the Legislature could not have intended.
Section 37 of the SABS addresses the question of an insurer’s discontinuance of a Benefit. Section 37 (4) states that where an insurer determines that its insured is no longer entitled to receive a specified Benefit, the insurer shall advise its insured of its determination based on the medical or other reason for its decision.
Section 37 (6) provides that after the insurer has received an IE report, the insurer shall provide its insured with notice of its determination and advise of the reasons for its decision.
With regard to the issue of Rehabilitation and Assessment expenses, section 38 (8) states that within 10 days of the insurer’s receipt of a treatment plan, the insurer shall notify its insured of the insurer’s intention to either pay it or not pay it and why the insurer believes that the Assessment or examination is not reasonable or necessary.
Section 38 (11) provides that a breach of subsection 38 (8) means that the insurer shall pay the Benefit or the cost of the examination or Assessment.