Turning now to the merits of the case at hand, I find that these two treatment plans were not assessed in an appropriate manner by the Insurer’s assessor, Angela Bertolo of D & D Disability Management. Without belabouring the point, State Farm’s assessor admitted on cross-examination that if she had been given all of the available information and had more carefully considered the O.T. in-home assessment report dated July 16, 2015 prepared by Theresa Rector and provided by Ms. Federico to State Farm, AND/OR if she had been informed by State Farm that Ms. Federico had not received any occupational therapy modalities whatsoever prior to submitting these two treatment plans in 2015, then her decision and recommendation(s) may/ would have been different. More telling than this, however, was the admission by State Farm in its final submissions that it conceded that the assessments were of no great value and that they would not be relying upon them.
This leaves me with very little more to decide. It is clear from the foregoing that the two OCF-18’s provided by Natalie Zaraska, O.T., dated February 23, 2015 and September 24, 2015 respectively, were reasonable and necessary.
Special Award:
Based upon the evidence received concerning the failure by State Farm to provide its O.T. Assessor with even the basic and obvious information required for her to determine that the Applicant had not, in fact, received any of the type of care set out in these treatment plans, it is clear that the two treatment plans subject to this arbitration were not properly denied or assessed. Therefore, I find that these two denials were unreasonable and the withholding of payment for these services was improper under the Schedule. Accordingly, I order a special award in the amount of $5,500.00, inclusive of interest, payable to the date of this order. This award is based upon the simple mathematics suggested by the Applicant’s counsel (and not specifically challenged by State Farm) which in my opinion results in an entirely appropriate calculation and avoids the delay inherent in the more usual approach of leaving the interest calculation to be determined after the fact by the Insurer’s accounting system. The calculation is as follows (for the rate of interest applied see below):