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.