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.