<Costs of examination for $20,765.25 including $19,000.00 for catastrophic determination assessments>

Issue: “Is the claimant entitled to the costs of examination in the amount of $20,765.25 including $19,000.00 for catastrophic determination assessments, $1000.00 for transportation and $765.25 for interpretation services?”

-1. Section 25(1)5 of the SABS stipulates that an insurer shall pay reasonable fees incurred by or on behalf of an insured charged for preparing an application under s. 45 for a determination of whether the insured is CAT, including any assessment necessary for that purpose. 

-2. Section 45(1) provides that an insured who sustains an impairment as a result of an accident may apply to the insurer for a determination of whether the impairment is catastrophic.

-3. Section 25(5)(a) limits the cost of any one assessment or examination to $2,000.00.

The insured/claimant bears the onus of proving on a balance of probabilities that each treatment and assessment plan is reasonable and necessary.

-4. The insurance company conducted a series of s.44 insurer assessments to determine the claimant’s entitlement to a CAT designation and, based on neuropsychological, psychiatric, physiatry and occupational therapy reports which have all been produced, this insurance company determined that the claimant/insured did sustain the catastrophic impairments under criterion 7 or 8 as a result of the accident.