claim | OLHI - OmbudService for Life & Health Insurance | Resolution of your Canadian Insurance Concerns | OLHI

OLHI OLHI – OmbudService for Life & Health Insurance | Resolution of your Canadian Insurance Concerns | OLHI

Mrs. T. purchased medical travel insurance ahead of a trip abroad. On that holiday, she fell ill and had to be treated in hospital. Afterward, she submitted her claim. It was declined because the insurance plan did not cover anyone who had been treated for three specific medical conditions. In its final position letter, the insurance company wrote that Mrs. T. had been treated for these conditions.

Mrs. T. contacted OLHI, asking for a free, independent review of her case. She told our Dispute Resolution Officer (DRO) that she had been diagnosed and treated for two of the medical conditions. But she had never been diagnosed or treated for the third condition: hypertension/high blood pressure.

OLHI’s DRO asked Mrs. T. and her insurance company to provide all their information relating to this case. In his review, he found that Mrs. T. was taking a medication for stroke management. The medication prescribed is also used to treat blood pressure. However, this was not the reason why it was prescribed for Mrs. T. In her case, it was for stroke management.

The DRO recommended that the case be escalated to an OmbudService Officer (OSO) for further investigation. Looking at all the files, the OSO read that Mrs. T.’s doctor had confirmed with the insurance company that she had never been diagnosed with high blood pressure. Although it was acknowledged that this particular medication is often prescribed for hypertension, Mrs. T. was taking it to control her history with strokes – and not hypertension/high blood pressure.

The OSO reached out to Mrs. T.’s insurance company and recommended they revisit the case. Because of a history of strokes, controlling blood pressure was necessary but it did not mean that she was hypertensive. The insurance company agreed with the OSO’s suggestion and paid out Mrs. T.’s claim for her hospital expenses.

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.

 

Mr. K. was a mechanic with chronic lower back pain. Eventually, he had to stop working. His employer’s group benefits plan covered his long-term disability (LTD) for two years on the basis that he was unable to perform the duties of his “own occupation” during this time.

To continue his disability benefits, Mr. K. would need to prove that he was unable to perform “any occupation” and unable to earn at least half of his pre-disability salary. The insurance company determined that he did not meet the criteria and denied his LTD claim.

Mr. K. came to OLHI with a final position letter from the insurance company. Our Dispute Resolution Officer (DRO) went through all the supporting documents from Mr. K. and the company. It appeared that the company may have declined the claim prematurely. For this reason, he recommended an OmbudService Officer (OSO) investigate further.

Through his review, the OSO learned that the insurance company based its assessment on medical records that were nearly a year old. Also, its own medical expert stated that more information was needed before making a recommendation on LTD benefits. Specifically, she suggested that the insurance company better understand Mr. K.’s current limitations and look into whether his doctor thought it was possible to work at a sedentary job. Our OSO also wondered why the insurance company had suggested alternate jobs for Mr. K. without fully understanding his current abilities and how much these alternate jobs paid.

OLHI contacted the insurance company and suggested that the decision to deny Mr. K.’s claim appeared to be based on insufficient evidence. He recommended that the insurance company reconsider its position. It agreed to do so and provided Mr. K. with a significant lump sum payment to settle his disability 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.

Ms. E. had extended health insurance through her employer. She disclosed that she suffered from seizures. This insurance also covered out-of-country emergency medical expenses. While on vacation, Ms. E. became ill and was hospitalized. Doctors determined that she had a bad reaction to a drug she was taking to treat a pre-existing condition. While in hospital, Ms. E. became worse due to an unrelated illness and had to return to Canada immediately.

The insurance company covered the costs of Ms. E.’s transportation back home to continue her care. However, in their final position letter, they stated they would not cover treatment for her reaction to the drug. The company decided that Ms. E.’s pre-existing condition extended to any side effects from medications taken for this condition.

Ms. E. asked OLHI to become involved. She told our Dispute Resolution Officer (DRO) that she believed her insurance company was setting a bad precedent. She said their decision could lead to denying coverage to any person on medication who suffers a side effect. For example, Ms. E. questioned what would happen if a person has a bad side effect from an over-the-counter pain reliever. Could the insurance company refuse to cover treatment, if this pain reliever treats a pre-existing condition?

The DRO recommended that an OmbudService Officer (OSO) investigate Ms. E.’s case. The OSO learned that a doctor saw Ms. E. when she returned to Canada. The doctor felt that it could not be proven with certainty that the Ms. E.’s problems were side effects of her medication. He suggested that her problems could have been caused by the unrelated illness she had after she was hospitalized.

The OSO contacted the insurance company’s Ombuds office. He advised that Ms. E.’s policy did not specify that it would not cover side effects from a medication. He also reinforced the fact that there was uncertainty around what caused Ms. E.’s illness. This made it impossible to tell, conclusively, that her treatment was for her pre-existing condition. He recommended that the insurer reconsider its position and pay Ms. E.’s claim.

The insurer, upon further reflection, agreed and provided payment on the out-of-country medical expenses.

 

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.

We’ve had a facelift!

What’s new?

  • Submitting a complaint is just a few clicks away! We are Canada’s only financial services OmbudService accepting document submissions online, using e-signature technology.
  • You can now search our website using keywords.
  • Have an old insurance policy? No problem – we will help you find out which company now holds your policy. OLHI is the only place in Canada that offers this information on mergers, acquisitions or renaming of old companies.

What’s been improved?

  • Finding insurance has a new look and feel. It is the same great service. OLHI is the only place in Canada that offers this comprehensive list of member companies and the products they sell.
  • We remain Canada’s only service that searches for policies of a deceased person. Consumers can now submit their search requests online.

Mr. Q. wanted to buy new glasses through his employer’s group health insurance plan. Employees could only buy new glasses every two years – a standard period for many plans. He could not remember the last time he bought glasses.

Logging onto the insurance company’s website, Mr. Q. accessed his personal list of transactions made over the last two years. He did not see any purchase for glasses during this time so he bought new glasses and submitted his claim.

The insurance company denied Mr. Q.’s claim because he had in fact purchased glasses the prior year. They said that this claim was listed under the website’s section about “My Claims” – and not under “My Transactions.” They explained that there were two lists on their website: one for claims that an employee filed online (My Transactions) and one for claims that employees filed manually (My Claims). Because Mr. Q. had submitted his glasses claim last year manually, it did not show up on his list of “My Transactions.”

The insurance company suggested that if Mr. Q. was dissatisfied with the decision, he could contact OLHI for a free, impartial review. He brought his final position letter to OLHI and a Dispute Resolution Officer (DRO) started to review his case. Mr. Q. explained to the DRO that the insurance company’s website doesn’t direct people to look under both sections. Mr. Q. felt that a reasonable person would not think to check both places as a list of transactions implies all transactions ever made through his benefit plan.

OLHI’s DRO noted that Mr. Q. had a point: the website did not warn that an employee should look at both lists because each list showed a history of claims transactions depending on the way they were submitted. For this reason, OLHI contacted the insurance company and explained how confusing the process could be for an employee and how a mistake of this nature could be made.

The insurance company agreed to reimburse Mr. Q. for half of the cost of the glasses and he accepted this offer.

 

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.

Mr. J. was diagnosed with prostate cancer and submitted a claim against his Critical Illness policy. His insurer declined his benefit, stating that his particular type of prostate cancer was at a stage that is not covered under his policy.

Mr. J. contacted OLHI with his insurer’s final position letter, telling our Dispute Resolution Officer (DRO) that his stage one cancer was on a list of exclusions – a list he never received from the insurer, so he was completely unaware of this detail. While Mr. J. did receive a one-page document outlining his schedule of coverage, he did not receive the complete policy package, known as the fulfillment kit, which would have also included a cover letter and detailed policy.

Upon further review by the DRO, he discovered that the insurer’s records confirmed that the fulfillment kit status was “pending print in print queue.” Based on this, there was reasonable doubt that Mr. J. did not get the kit. He recommended that an OmbudService Officer (OSO) investigate.

OLHI’s OSO agreed that it was reasonable for Mr. J. to assume that he was covered, just based on the one-page document of information he had.

Because this one page included Mr. J.’s address and did not reference any other documents, there was logic in Mr. J. believing this page formed his complete policy. In Ontario, by law, an insurer must deliver a policy to the insured and the insured has the right to review and agree to it. The OSO suggested that because Mr. J. did not get his fulfillment kit, he was deprived of his right to examine and agree to the complete policy.

As a result, the OSO contacted Mr. J.’s insurer and recommended they reconsider their decision, given the technical problem and reasonable doubt. As a gesture of good faith, the insurer agreed to pay out 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.

Ms. A. wrote to OLHI seeking assistance after she had unsuccessfully appealed her insurer’s decision to discontinue her disability benefits. Her group disability plan provided payments for a period of 24 months upon inability to perform her own occupation. In order to qualify for benefits after that period, she was required to provide evidence of inability to perform any occupation for which she was reasonably suited by education, training or experience.

This matter was directed to an OLHI Dispute Resolution Officer (DRO) experienced in disability claims. He followed up with Ms. A. and learned that she was a physiotherapy assistant, a highly physical job. Several years before, she had sustained a leg fracture requiring surgery. She had submitted a claim for disability payments under her group disability program and was granted benefits. He also learned that Ms. A. had cooperated with the insurer’s efforts to get her back to work by actively participating in a prescribed rehabilitation plan and by undergoing a functional capacities evaluation (FCE) to determine her capacity to work. Following the FCE, Ms. A. received a letter from her insurer advising that her benefits would terminate in six months’ time, upon conclusion of the “own occupation” period. Ms. A. appealed her insurer’s decision to terminate benefits on several occasions without success.

Following their conversation, our DRO reviewed the documentation that he had requested from her. This included correspondence with her insurer, medical reports, the FCE, and materials she had submitted to CPP in support of a claim for disability benefits. He noted that although the insurer had concluded from the FCE that Ms. A. could do “sedentary work”, the report itself indicated only “perceived ability at sedentary, tolerated light capacities.” No Transferable Skills Analysis (TSA) had been undertaken by the insurer to support a conclusion that Ms. A. had the skills and capacity to transition to a sedentary occupation, such as secretarial or receptionist duties.

He also observed that the insurer, in making its decision to end benefits, appeared to give significant weight to the fact that during the initial benefit period, Ms. A. had excelled in a six week training course in medical terminology and had also responded to job advertisements in which she might apply these skills. In addition, it was noted that there was clear and credible evidence of deterioration in her medical condition in the two years following the termination of her benefits.

All of these factors were instrumental in our DRO concluding that there were grounds to refer this complaint to an OLHI OmbudService Officer (OSO) for a more thorough review.

The OSO reviewed the file, spoke at length with Ms. A., and determined that the next step should be a review of the insurer’s claim file. In accordance with OLHI’s procedures, the insurer readily produced this file upon request.

Upon reviewing the insurer’s file, it appeared that the denial of Ms. A.’s disability claim was based on an apparently successful vocational rehabilitation program and the FCE performed 18 months into her 24-month initial claim period.

On the other hand, the insured’s physical and mental condition had been deteriorating and she had clearly struggled to complete her rehabilitation program to prevent loss of her benefits. Also noted were conflicting views in the insurer’s own file as to the likelihood of her ability to function in any kind of work setting. Moreover, while Ms. A.’s original application for CPP disability benefits had been initially denied, her claim was subsequently approved.

Upon conclusion of his review, the OSO made a detailed written submission to the insurer with a recommendation that the insurer review its decision.

In due course, the insurer responded with an offer to have Ms. A. submit to an independent medical examination. This examination determined that she was, indeed, unable to function in any occupation for which she might be reasonably suited by education, training, or experience.

The insurer accepted the independent medical examiner’s assessment and promptly agreed to allow benefits on a continuing basis, subject to an appropriate adjustment with respect to the CPP benefits already received.

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.

When Mr. G. purchased a trailer, he enrolled in the group creditor insurance plan offered by the dealership. His paperwork confirmed he had requested both life and disability insurance in connection with the financing on his trailer.

He subsequently became disabled and contacted the dealership about submitting a disability claim to cover his loan payments while he was unable to work. It was then that he learned the loan on his trailer carried life insurance only, despite the paperwork he had in his possession.

Mr. G. confronted the dealership representative about the problem with his coverage. The representative admitted responsibility and confirmed he had made a mistake. At one point, the dealer even offered to pay the disability premium on Mr. G.’s behalf but subsequently reneged on the offer.

By the time he called OLHI, Mr. G. had made numerous attempts to resolve the problem on his own, to no avail. He was very frustrated, particularly because it was not clear with whom he should be dealing. Should he pursue his complaint with the dealership, the insurer’s third party administrator, or the insurance company itself? On the surface, it appeared that he had been disadvantaged as a result of the actions of the dealership, not the insurer nor its administrator. However, additional fact finding would be required to determine the best course of action to resolve the situation.

As a first step, an OLHI Dispute Resolution Officer (DRO) called the third party administrator, whose role it is to administer the insurance plan on behalf of the insurer. It was confirmed that only a life insurance certificate had been issued for Mr. G. and that he had no disability coverage in place. At this point, our DRO became concerned that even if Mr. G. or the dealership would agree to pay the premium for the disability insurance, the insurer would not agree to entertain Mr. G.’s disability claim. Accordingly, our DRO wrote to the insurer’s Ombuds Officer, apprising him of the situation and enquiring whether the insurer would consider Mr. G.’s disability claim if it received payment of the premium.

The insurer’s representative advised OLHI that it was conducting an investigation into the matter. They had already spoken with the dealership and were in the process of contacting Mr. G. to obtain his side of the story. Our DRO subsequently followed up and inquired, once again, if the insurer would accept responsibility for the claim if its’ investigation showed that the dealership was at fault and the premium was subsequently paid. She was advised that the insurer’s Ombuds would confer with senior management.

Eventually, a settlement was reached whereby the dealership agreed to pay half of the disability premium, Mr. G. agreed to pay the other half and the insurer agreed it would consider the disability claim upon receipt of the full premium.

Mr. G. expressed his gratitude for OLHI’s assistance in concluding a settlement that ensured his disability claim would be considered, thus satisfying his original expectation that he was insured in the event of disability.

 

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.

By continuing your navigation on this site, you accept the use of cookies.

These are designed to improve your user experience on our site by collecting traffic statistics and information on your behaviour.

More information on our Privacy Policy