Ms. M. called OLHI to seek assistance with reinstatement of her disability benefits. Initial discussions with one of our Dispute Resolution Officers revealed that she had received long-term disability benefits for a period of well over two years. Payments were stopped on the basis that she was not cooperating with the rehabilitation program arranged by her insurance company, as evidenced by several missed treatment sessions. There was also an underlying suspicion by the insurance company that Ms. M. may have been “malingering.” Accordingly, the complaint was referred to one of our OmbudService Officers (OSO) for a more detailed examination.
As is the norm, Ms. M.’s group disability plan provided benefits for a 24-month period upon satisfactory proof that she was unable to perform the duties of her own pre-disability occupation. To qualify for benefits after that period, she was required to provide satisfactory evidence that she was unable to perform any occupation for which she was “reasonably suited” by education, training or experience.
The OSO assigned to the case noted that the insurer had continued to accept Ms. M.’s disability beyond the initial 24-month period but had apparently become concerned about the potential duration of the claim due to Ms. M.’s relatively young age. As a result, Ms. M.’s insurer prescribed a rehabilitation program with a view to assessing her ability to return to the work force.
Our Officer spoke at length with the insured and determined that this case would best be served by his independent review of the insurer’s claim file. The insurer readily agreed.
Through the course of his investigation and analysis, our OSO noted that there were conflicting issues and points of view. The insurer’s concern about the claim was perfectly understandable. To its’ credit, the insurance company had continued the claim well beyond the 24-month initial period and had decided to invest in Ms. M.’s rehabilitation. On the other hand, our Officer’s review suggested that the design of the insurer’s rehabilitation program may have been ill suited to Ms. M.’s disability.
He was also concerned about the insurer’s deeply engrained suspicion of malingering, which did not seem to be firmly grounded in the facts. Specifically, a conclusion of malingering was not supported by the observations of the attending physician nor by Ms. M.’s willing participation in various other alternative treatments designed to alleviate her disability.
Upon conclusion of his review, the OSO prepared a detailed written submission to the insurer. He acknowledged the insurer’s support of the claim and decision to invest in Ms. M.’s rehabilitation. On the other hand, he pointed out that Ms. M.’s disability under the policy was not in dispute and that her inability to consistently attend all rehabilitation sessions was likely explained by the unsuitability of the rehabilitation program, rather than a lack of desire to “cooperate” with a suitable program.
With the benefit of having reviewed this complaint from an independent perspective, the Officer also suggested that the insurer’s suspicion of malingering was not supported by the facts.
The insurance company agreed to consider our OSO’s perspective and quickly responded with an offer that resolved the complaint to the satisfaction of both parties. In sum, the insurer agreed to reinstate Ms. M.’s claim retroactively on the understanding that she would follow a new rehabilitation program suitable for her medical condition, developed in consultation with her attending physician. Both parties were satisfied with the result and we understand that Ms. M. is now successfully following her new rehabilitation program.
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.