Case Study – OLHI – Free, impartial help with your life & health insurance complaints

Dale had a universal life insurance policy. 

When his insurance company told him they were going to charge him another premium for the policy, Dale decided to terminate it. 

To avoid a Cost of Insurance (COI) charge, the insurer told Dale to send a signed insurance cancellation letter to the same day he terminated his policy.

However, Dale’s insurer didn’t inform him that he needed to include his social insurance number (SIN) in the termination letter. Without the SIN, his policy termination got delayed and Dale was charged the COI. As a result, he received a lower refund than expected. 

After he received a final position letter from the insurer, Dale reached out to OLHI to review his complaint.

OLHI’s review confirmed that his insurance company did not tell Dale he had to include his SIN in the letter. 

OLHI’s review also found that even after Dale sent in the letter with his SIN, the company asked for it again. OLHI recommended that the insurer reconsider the COI charge for two reasons:

The company did not initially communicate that Dale needed to include his SIN in his termination letter. 

When the insurer said Dale needed to include the SIN, he did so, and sent the termination letter within the same day, so the company should have processed it effective as of the receipt date. 

Consequently, the insurer agreed and backdated the termination and refunded the COI charge.

Disclaimer: Names, places and facts have been modified in order to protect the privacy of the parties involved. This case study is for illustration purposes only. Each complaint OLHI reviews contains different facts and contract wording may vary. As a result, the application of the principles expressed here may lead to different results in different cases.

An elderly man named Fred fell and went to hospital with a head injury. He was discharged the next day. His son cared for him at home.

Soon after, Fred had headaches and bouts of vomiting and returned to hospital. When he was discharged a month later, he moved into long-term care as he was unable to walk.

Fred asked his son to submit an accident benefits claim on his behalf to pay for his medical expenses.

Fred’s insurer denied the claim. His son appealed, but the company upheld its final position.

When Fred’s son received the insurance company’s final position letter, he came to OLHI for help.

OLHI’s complaints team reviewed the complaint. We discovered that the original accident benefits claim did not have all of the available information about Fred’s injuries and hospital stays.

Based on hospital records, it was clear that both of Fred’s hospital stays were a result of his fall.

OLHI recommended that the insurer reconsider covering Fred’s hospital expenses.

The insurer paid the claim because of this new information.

Disclaimer: Names, places and facts have been modified in order to protect the privacy of the parties involved. This case study is for illustration purposes only. Each complaint OLHI reviews contains different facts and contract wording may vary. As a result, the application of the principles expressed here may lead to different results in different cases.

Mike W. worked in construction all his life until he hurt his back.

Unable to work since his injury, he was declared “totally disabled” by the Régie des Rentes du Québec (“RRQ”).

The credit insurance Mike purchased when he took out his mortgage covered his monthly payments. In the event of disability, it would pay 150% of all mortgage-related expenses and waive all monthly premiums.

But after 12 months, the insurer stopped all payments and began charging Mike his monthly credit insurance premiums.

This was when Mike came to OLHI. He believed that his insurer should cover his remaining mortgage because the RRQ had confirmed he was “totally disabled”. His medical condition had not improved, and he thought he was unable to work.

We explained that disability benefits typically cover an initial period based on the inability to perform one’s own occupation. But for benefits to continue, Mike needed to show that he was unable to perform any occupation. The RRQ’s declaration that Mike was “totally disabled” did not necessarily prove that he was “unable to perform any occupation.”

We advised Mike to contact his insurer and formally ask for a review of his file. 

Mike negotiated an agreement with his insurer to pay off his mortgage. In exchange he waived his entitlement to the additional 50% benefits and reimbursement of his credit insurance premiums.

Disclaimer: Names, places and facts have been modified in order to protect the privacy of the parties involved. This case study is for illustration purposes only. Each complaint OLHI reviews contains different facts and contract wording may vary. As a result, the application of the principles expressed here may lead to different results in different cases.

Lisa D.’s son has cerebral palsy, and his doctor recommended a treatment to help manage it.

Lisa’s group health benefits provider verbally affirmed that the treatment was covered under her plan. But when the company followed up in writing, it informed her that the proposed treatments were ineligible for coverage unless she could provide information proving they were medically required.

Lisa sent the company a letter from her son’s doctor justifying the treatments. The insurer still denied the claim in its final position letter.

Feeling lost and confused, Lisa came to OLHI for help. We reviewed her group health benefits policy. The policy’s definition of “eligible expense” had many conditions, used confusing wording, and didn’t clearly explain why Lisa’s claim was ineligible.

We contacted the insurer to learn more. They said the proposed treatments were not eligible because the policy only covered the cost of medical equipment, not the treatments themselves. Lisa was unaware of this condition until after she received the written follow-up.

Further review also found that the insurer took the position that the policy only covered medical equipment after it told Lisa it would pay for “medically reasonable” treatments.

We recommended that the insurer reconsider their position and cover the treatments for Lisa’s son because of the confusing communication with Lisa.

The insurer agreed, and Lisa’s son began his treatment.

Disclaimer: Names, places and facts have been modified in order to protect the privacy of the parties involved. This case study is for illustration purposes only. Each complaint OLHI reviews contains different facts and contract wording may vary. As a result, the application of the principles expressed here may lead to different results in different cases.

When Jim found out he had stage one prostate cancer, he submitted an insurance claim.

His insurer denied the claim, saying stage one prostate cancer was not covered by his Critical Illness insurance policy.

When Jim received his insurer’s final position letter, he came to OLHI.

Our complaints team reviewed the case and learned that stage one prostate cancer was, in fact, not covered by Jim’s policy. But we also learned that Jim had never received this information from the company.

When his Critical Illness coverage started, the company had sent Jim a one-page document outlining his policy. It did not include information about what illnesses the policy did not cover.

Usually, when a consumer purchases insurance, the company will send a package of information with all the policy details. OLHI’s review discovered the company never sent Jim the fulfilment package due to administrative error.

As a result, OLHI believed Jim had a reasonable expectation that his prostate cancer should be covered.

We contacted his insurer and recommended it reconsider paying Jim’s claim, given the administrative error and reasonable doubt that Jim knew his type of cancer was not covered.

As a gesture of good faith, the insurer agreed to pay the claim.

Disclaimer: Names, places and facts have been modified in order to protect the privacy of the parties involved. This case study is for illustration purposes only. Each complaint OLHI reviews contains different facts and contract wording may vary. As a result, the application of the principles expressed here may lead to different results in different cases.

Harold B. suffered a severe health problem related to his kidneys and had to have one removed. Worried about his clients, Harold returned to his job as soon as he felt able after the surgery.

When Harold returned to work, he had to periodically reduce his work hours and was never able to work full-time again because of his health. Nearly two years later, Harold quit his job and submitted a total disability claim to his individual disability insurance provider.

The insurance company denied the claim, even after Harold appealed the decision. At this point, Harold came to the OmbudService for Life and Health Insurance.

OLHI reviewed the complaint and learned:

  • Harold’s policy only covered losses for “total disability.”
  • He had returned to work part-time and before he completed the waiting period required by his policy.
  • Harold submitted his final claim after the policy deadline.
  • The insurer’s decision strictly followed the policy’s terms, but the company could have communicated the process earlier and more clearly to Harold.

As OLHI cannot consider damages or extenuating circumstances outside of insurance policy, we advised Harold to consider pursuing his complaint in court with a disability lawyer.

Disclaimer: Names, places and facts have been modified in order to protect the privacy of the parties involved. This case study is for illustration purposes only. Each complaint OLHI reviews contains different facts and contract wording may vary. As a result, the application of the principles expressed here may lead to different results in different cases.

Mrs. T. purchased medical travel insurance ahead of a trip abroad. On that holiday, she fell ill and had to be treated in hospital. Afterward, she submitted her claim. It was declined because the insurance plan did not cover anyone who had been treated for three specific medical conditions. In its final position letter, the insurance company wrote that Mrs. T. had been treated for these conditions.

Mrs. T. contacted OLHI, asking for a free, independent review of her case. She told our Dispute Resolution Officer (DRO) that she had been diagnosed and treated for two of the medical conditions. But she had never been diagnosed or treated for the third condition: hypertension/high blood pressure.

OLHI’s DRO asked Mrs. T. and her insurance company to provide all their information relating to this case. In his review, he found that Mrs. T. was taking a medication for stroke management. The medication prescribed is also used to treat blood pressure. However, this was not the reason why it was prescribed for Mrs. T. In her case, it was for stroke management.

The DRO recommended that the case be escalated to an OmbudService Officer (OSO) for further investigation. Looking at all the files, the OSO read that Mrs. T.’s doctor had confirmed with the insurance company that she had never been diagnosed with high blood pressure. Although it was acknowledged that this particular medication is often prescribed for hypertension, Mrs. T. was taking it to control her history with strokes – and not hypertension/high blood pressure.

The OSO reached out to Mrs. T.’s insurance company and recommended they revisit the case. Because of a history of strokes, controlling blood pressure was necessary but it did not mean that she was hypertensive. The insurance company agreed with the OSO’s suggestion and paid out Mrs. T.’s claim for her hospital expenses.

Disclaimer: Names, places and facts have been modified in order to protect the privacy of the parties involved. This case study is for illustration purposes only. Each complaint OLHI reviews contains different facts and contract wording may vary. As a result, the application of the principles expressed here may lead to different results in different cases.

 

Mr. and Mrs. H. applied for life insurance and were approved. When her husband died several months later, Mrs. H. claimed the benefits under the policy. The insurance company denied the claim for failing to disclose information about Mr. H.’s health.

Mrs. H. brought her final position letter to OLHI. She explained to our Dispute Resolution Officer (DRO) that a nurse had come to their home on behalf of the insurance company to collect blood and urine samples and fill out a questionnaire. During their conversation, Mr. H. told her about his high iron levels and his visits to a hematologist. The nurse noted “blood work normal” in her report despite his disclosure. Mrs. H. and her husband gathered the high iron was not important since the nurse did not take it into account, nor did the insurance company analyze his blood for this.

After his review of the information from Mrs. H. and the insurance company, the DRO recommended an OmbudService Officer (OSO) investigate further.

The OSO discovered that the company had not contacted the nurse to find out more about her visit with Mr. and Mrs. H. He recommended Mrs. H. contact this nurse, to see if she could validate their conversation. The nurse was unable to recall the specifics of their meeting.

While Mr. H.’s medical records showed he had been diagnosed with a blood condition, it was not disclosed in his insurance application. However, Mr. H. had signed this application, along with the report that the nurse prepared, confirming that all information provided was accurate. For this reason, the OSO recommended that there was no reason to further pursue this complaint.

Disclaimer: Names, places and facts have been modified in order to protect the privacy of the parties involved. This case study is for illustration purposes only. Each complaint OLHI reviews contains different facts and contract wording may vary. As a result, the application of the principles expressed here may lead to different results in different cases.

Mrs. R. frequently traveled out of country. She purchased a travel health insurance plan that would cover her for 35 days every time she left Canada. She departed in February and in May, while still on her holiday, she suffered a major illness, was hospitalized and passed away two weeks later.

While Mrs. R. was in hospital, her son, Mr. R., became involved. When he and the doctors reached out to the insurance company, the company confirmed that it would be able to help. Mrs. R. was transferred from one hospital to another for specialized care – a transfer that the company helped coordinate.

The insurance company denied the claim because the policy’s coverage had expired. In its final position letter, the company told Mr. R. about how OLHI reviews matters that consumers have not been able to resolve with their company. He contacted OLHI and asked a Dispute Resolution Officer (DRO) to become involved.

Mr. R. told the DRO that the company confirmed several times that his mother would be covered by the policy. He had no idea that her coverage was for only 35 days because he did not find this out from the company until after incurring costs.

Because of the complexity of the complaint, the DRO recommended that an OmbudService Officer (OSO) become involved to further delve into the investigation and to determine whether there were grounds for conciliation.

The OSO reviewed documents provided by all parties. He also listened to the recordings of telephone calls between Mr. R. and the company, as well as between the hospital and the company. In these calls, the company said that it would help with the hospital transfer but that it was not a guarantee of coverage because the claim still had to be processed and reviewed for approval. In those conversations, the company did not yet know when Mrs. R. had left on her out-of-country trip.

The OSO recommended that there were no grounds to pursue. The company’s claims process included confirming the coverage period. He also agreed that while the company said that Mrs. R. had insurance coverage, it also said that her claim still had to be reviewed to confirm she met the policy’s terms of coverage.

Disclaimer: Names, places and facts have been modified in order to protect the privacy of the parties involved. This case study is for illustration purposes only. Each complaint OLHI reviews contains different facts and contract wording may vary. As a result, the application of the principles expressed here may lead to different results in different cases.

Ms. C. worked as an office administrator, a predominantly sedentary role. She began to experience medical conditions that affected her back. Her employer’s group disability insurance plan covered her short-term disability claim. After several months, the insurance company denied Ms. C.’s coverage for long-term disability (LTD), stating that her illness did not prevent her from performing her job. The final position letter explained that Ms. C’s illness lacked clinical medical information to satisfy the terms of the disability contract.

After receiving this letter, which pointed to OLHI as an independent dispute resolution service, Ms. C. approached OLHI. In her review, OLHI’s Dispute Resolution Officer (DRO) noted that medical reports determined Ms. C. was not fit for work and that her condition was deteriorating. Meanwhile, the insurance company interpreted the reports differently, finding there was an improvement in her condition. The DRO also questioned whether the insurance company was relying too much on looking for neurological evidence that did not directly correlate with Ms. C.’s diagnosis from her doctor and specialist.

With these questions in mind, the DRO recommended an OmbudService Officer (OSO) further investigate Ms. C.’s complaint.

OLHI’s OSO learned that the tests conducted on Ms. C. returned with negative or mild/moderate results. Medical reports recommended that she could still perform sedentary or light duties, fitting with her job description, and her doctor supported a gradual return to work program. However, Ms. C.’s employer declined the program and instead ordered an independent medical examination, which concluded that she was not fit to work. Meanwhile, other conflicting medical reports suggested that Ms. C.’s condition was deteriorating because of an unhealthy lifestyle and not because of her diagnosis affecting her back.

Given the conflicting information and the employer’s refusal to have Ms. C. return to work because of its own medical findings, the OSO recommended that the insurance company and the employer reach an agreement. With OLHI’s recommendation, Ms. C. was able to reach a settlement.

Disclaimer: Names, places and facts have been modified in order to protect the privacy of the parties involved. This case study is for illustration purposes only. Each complaint OLHI reviews contains different facts and contract wording may vary. As a result, the application of the principles expressed here may lead to different results in different cases.

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