When Ms. W. went on long-term disability after suffering degenerative disease in her knees, both her individual disability benefit plan provider and the Canada Pension Plan accepted her disability and began paying out her claim. However, when she submitted her claim to her group plan provider, through her employer, she was declined, much to her surprise and confusion.
The insurer explained that definitions of disability differ between insurers and between policies; as a result, an insurer could not base a decision on that of another. Ms. W.’s insurer stated, in its final position letter, that although medical notes indicated inability to deep knee bend, kneel or run, they did not mention any difficulty with sitting or complete intolerance to any driving, walking or standing. For this reason, the insurer noted that their claim denial decision was made based on the level of information provided.
When Ms. W. contacted OLHI, a Dispute Resolution Officer (DRO) learned from Ms. W. that she did in fact have trouble sitting for long periods of time and as such could not work full time – and any part time income would not equal what she was earning either in a job or through disability payments. Jobs in her field required a lot of manual labor, which she could no longer perform.
The DRO also discovered, when going through Ms. W.’s file, the insurer’s medical consultant had suggested that more tests be undertaken – none of which were run or requested by the insurer. Additionally, all medical notes from Ms. W.’s doctors noted that her condition would likely worsen over time, making it increasingly difficult to perform physical tasks.
Based on this information, the DRO recommended the case be escalated to an OmbudService Officer (OSO). The OSO’s investigation revealed reports from the family doctor, written after the claim period in question. The doctor wrote that Ms. W. could not spend time in any particular position (sitting/standing) for more than a few minutes at a time, making it impossible for her to drive to a job and work. The insurer had also noted in its file that, given her relatively young age, she be assessed to determine whether any jobs would be best suited for her. The insurer suggested Ms. W. could be capable of certain jobs in her industry that are sedentary with the ability to change her body’s position frequently, from sitting to standing. This belief was further confirmed by a medical note in Ms. W.’s file, written by her doctor, where he suggested she be trained to perform a sedentary job.
Resulting from our OSO’s extensive research into the case, where he spoke with the consumer, her doctors and the insurer, he concluded that the medical records available for the specific time period at hand did not support complete inability to perform work. The OSO advised that it was his recommendation that the insurer’s decision be upheld.
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.