Mrs. Q. began to see an acupuncturist, paying in advance for a package deal that would reduce the price of each individual treatment. In order to receive reimbursement through her group health plan, she had to have a prescription from her family doctor and had to select an acupuncturist certified by a governing board. Mrs. Q. had the prescription but her province did not have a governing board for these practitioners. She selected a certified acupuncturist but, when she submitted her claim, the insurer denied it based on the fact that his credentials were not recognized by them.
As a goodwill gesture, the insurer agreed to cover the costs of the sessions Mrs. Q. went to up to the date of their denial (approximately half of the sessions she’d bought) but would not absorb any costs going forward. She appealed the decision, stating that she had paid for the sessions up front and could not cancel the rest. She also claimed that there was no way for her to know whether or not her acupuncturist’s credentials were recognized by the insurer.
Mrs. Q. contacted OLHI and our Dispute Resolution Officer (DRO) learned that Mrs. Q. had not yet received a final position letter from her insurer. He recommended that she contact the insurer’s Ombudsman and request a final position letter, at which point OLHI could become involved. A couple of weeks following this conversation, Mrs. Q. received this letter and called back the DRO.
The DRO learned that Mrs. Q.’s coverage booklet from her employer did not outline that services would only be covered if the acupuncturist was recognized by certain associations, of which this particular acupuncturist was not a part of. Mrs. Q. could not cancel her future sessions, having paid up front. She asserted that the full package should be covered by the insurer.
With this information, the DRO recommended the case be escalated to the OmbudService Officer (OSO) level to see if there was any room for negotiation with the insurer and to further investigate the reasoning behind their claim denial.
OLHI’s OSO reached out to the insurer’s Ombudsman’s office to further discuss the case, indicating that he felt Mrs. Q. had some valid arguments, based on preliminary findings. It was over the course of the OSO’s exchanges of information that he discovered Mrs. Q.’s employer had received a notice from the insurer the year prior – long before Mrs. Q. arranged for acupuncture treatments. This notice outlined the insurer’s criteria for acceptance of an acupuncturist and a list of recognized associations. Additionally, the notice recommended that employees should submit an estimate to the insurer before going to any expense, so the insurer could review that specific acupuncturist’s credentials.
The insurer acknowledged that it’s possible Mrs. Q. did not see this notice, for any host of reasons – but that it’s the responsibility of employers to ensure such information is properly passed on to employees.
The OSO agreed that the insurer’s decision be maintained, believing it was fair that half the claim had been paid despite the fact that others were responsible for the unfortunate turn of events.
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.