disability – OLHI – Free, impartial help with your life & health insurance complaints

Mortgage relief – OLHI helps construction worker with disability insurance

Posted on: September 2, 2021

Mike W. worked in construction all his life until he hurt his back.

Unable to work since his injury, he was declared “totally disabled” by the Régie des Rentes du Québec (“RRQ”).

The credit insurance Mike purchased when he took out his mortgage covered his monthly payments. In the event of disability, it would pay 150% of all mortgage-related expenses and waive all monthly premiums.

But after 12 months, the insurer stopped all payments and began charging Mike his monthly credit insurance premiums.

This was when Mike came to OLHI. He believed that his insurer should cover his remaining mortgage because the RRQ had confirmed he was “totally disabled”. His medical condition had not improved, and he thought he was unable to work.

We explained that disability benefits typically cover an initial period based on the inability to perform one’s own occupation. But for benefits to continue, Mike needed to show that he was unable to perform any occupation. The RRQ’s declaration that Mike was “totally disabled” did not necessarily prove that he was “unable to perform any occupation.”

We advised Mike to contact his insurer and formally ask for a review of his file.

Mike negotiated an agreement with his insurer to pay off his mortgage. In exchange he waived his entitlement to the additional 50% benefits and reimbursement of his credit insurance premiums.

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.

OLHI clarifies insurer’s position in disability complaint

Posted on: June 8, 2021

Harold B. suffered a severe health problem related to his kidneys and had to have one removed. Worried about his clients, Harold returned to his job as soon as he felt able after the surgery.

When Harold returned to work, he had to periodically reduce his work hours and was never able to work full-time again because of his health. Nearly two years later, Harold quit his job and submitted a total disability claim to his individual disability insurance provider.

The insurance company denied the claim, even after Harold appealed the decision. At this point, Harold came to the OmbudService for Life and Health Insurance.

OLHI reviewed the complaint and learned:

Harold’s policy only covered losses for “total disability.”

He had returned to work part-time and before he completed the waiting period required by his policy.

Harold submitted his final claim after the policy deadline.

The insurer’s decision strictly followed the policy’s terms, but the company could have communicated the process earlier and more clearly to Harold.

As OLHI cannot consider damages or extenuating circumstances outside of insurance policy, we advised Harold to consider pursuing his complaint in court with a disability lawyer.

Conflicting medical reports (disability)

Posted on: June 26, 2017

Ms. C. worked as an office administrator, a predominantly sedentary role. She began to experience medical conditions that affected her back. Her employer’s group disability insurance plan covered her short-term disability claim. After several months, the insurance company denied Ms. C.’s coverage for long-term disability (LTD), stating that her illness did not prevent her from performing her job. The final position letter explained that Ms. C’s illness lacked clinical medical information to satisfy the terms of the disability contract.

After receiving this letter, which pointed to OLHI as an independent dispute resolution service, Ms. C. approached OLHI. In her review, OLHI’s Dispute Resolution Officer (DRO) noted that medical reports determined Ms. C. was not fit for work and that her condition was deteriorating. Meanwhile, the insurance company interpreted the reports differently, finding there was an improvement in her condition. The DRO also questioned whether the insurance company was relying too much on looking for neurological evidence that did not directly correlate with Ms. C.’s diagnosis from her doctor and specialist.

With these questions in mind, the DRO recommended an OmbudService Officer (OSO) further investigate Ms. C.’s complaint.

OLHI’s OSO learned that the tests conducted on Ms. C. returned with negative or mild/moderate results. Medical reports recommended that she could still perform sedentary or light duties, fitting with her job description, and her doctor supported a gradual return to work program. However, Ms. C.’s employer declined the program and instead ordered an independent medical examination, which concluded that she was not fit to work. Meanwhile, other conflicting medical reports suggested that Ms. C.’s condition was deteriorating because of an unhealthy lifestyle and not because of her diagnosis affecting her back.

Given the conflicting information and the employer’s refusal to have Ms. C. return to work because of its own medical findings, the OSO recommended that the insurance company and the employer reach an agreement. With OLHI’s recommendation, Ms. C. was able to reach a settlement.

Planning for illness and disability

Posted on: March 14, 2017

Most Canadians would rather not think about the possibility of a serious illness or accident. The Globe and Mail reports that one in three Canadians will be disabled for 90 days or more at least once before the age of 65.

The need for disability insurance

Posted on: January 31, 2017

There’s never been a better time to ensure that clients have disability insurance, writes the Insurance & Investment Journal.

Disability products most frequent source of complaints – Insurance & Investment Journal

Posted on: September 21, 2016

Read about OLHI in the Insurance & Investment Journal.

Steady work (disability)

Posted on: June 15, 2016

Ms. H. worked at the front desk of her family’s automotive shop. Her responsibilities were administrative in nature: assisting customers on the phone and in person, processing warranties, selling parts over the counter and traveling around the city to pick up parts. In October, she applied for disability under the company’s group plan, indicating on the application that she was diagnosed with a respiratory disease.

Three months later, Ms. H.’s family doctor recommended that she be treated with steroids and other medications for respiratory tract infections. She concluded that Ms. H. was not fit for work, except for very sedentary work in a clean environment that would not affect her respiratory disease. Ms. H applied for and was granted disability through the Canadian Pension Plan because her chronic illness and limitations met CPP’s definition of “disabled.”

Ms. H.’s insurance company, through her employee group plan, however, declined her disability claim. They said she had suffered from respiratory problems for many years, before the insurance coverage began. This made her illness pre-existing. The company also said that she was not permanently employed for 24 hours per week and was therefore not insurable.

OLHI became involved when Ms. H. sent us the company’s final position letter and all her documentary evidence. She explained to our Dispute Resolution Officer (DRO) that she was very unwell and unable to work a steady job. The DRO reviewed Ms. H.’s paperwork, as well as files that the insurance company sent. Medical reports confirmed her condition was worsening and made work impossible. With this information, the DRO recommended an OmbudService Officer (OSO) investigate.

The OSO discovered in the insurance policy booklet that an employee’s eligibility for benefits is based on the number of hours worked. A minimum of 24 hours of work was required each week. Ms. H.’s employer could not provide evidence of her hours worked and also admitted that they had paid her when she was ill, even when she did not work. Despite her illness, and despite the insurance company’s empathy, the OSO agreed that Ms. H. could not be covered under the plan.

If the shoe fits… (disability)

Posted on: June 15, 2016

Mr. N. was a 54-year-old floor porter, moving packages, equipment and other items around a hospital emergency room. His job required him to be on his feet eight hours a day. His uncontrolled diabetes led to a bone infection in his right big toe and he went on disability benefits through his employer’s group insurance plan. The insurance policy provided disability payments for the first 24 months so long as Mr. N. was not able to perform the essential duties of his job.

For the first six months, the insurance company paid Mr. N.’s disability benefits. Then, the company stopped, explaining that his infection was resolved and his condition did not prevent him from returning to work.

Mr. N. brought the company’s final position letter to OLHI. He told our Dispute Resolution Officer (DRO) that he could not return to his job because it required that he wear safety shoes. The bone infection had caused a deformity and limited sensation in his leg. The constant friction caused pain when he wore safety shoes. Additionally, he had dizziness from his diabetes.

Our DRO carefully reviewed all Mr. N.’s files, as well as the files sent by the insurance company. She learned that Mr. N.’s medical records confirmed that it was unlikely he could return to work in steel-toed boots. He was unable to properly stand on his feet, his walking was slow and his reflexes impaired. Mr. N.’s employer also confirmed that safety shoes were mandatory for the job.

The DRO recommended an OmbudService Officer (OSO) conduct a further review based on merit, given the physical nature of Mr. N.’s work. The OSO contacted the insurance company after his own through review, recommending that the medical evidence was quite definitive and prevented Mr. N. from performing the duties of his job. The insurance company agreed and continued to pay for his disability benefits for the rest of the 24 months.

Objective medical evidence (disability)

Posted on: February 2, 2016

Ms. V. was being treated for major depression and anxiety disorder. Her insurer accepted her disability claim on the basis that she was not able to perform the essential duties of her job as an office manager of a busy, professional firm.

Midway through that benefit period, the insurer discontinued her group benefits because Ms. V. opted to try to start her own business out of her home. The insurer’s final position was that the objective medical evidence on file suggested that her impairment was not sufficiently severe to prevent her from returning to her pre-disability job.

Ms. V. contacted OLHI for an independent, free review of her case. Our Dispute Resolution Officer (DRO) gauged that the diagnosis, symptoms and treatment hadn’t changed from the period during which Ms. V. received disability coverage. For this reason, he recommended the case be investigated by an OmbudService Officer (OSO).

OLHI’s OSO reviewed the file and questioned how, with the evidence on file, the insurer could conclude that Ms. V. was able to resume performing the skills of her prior demanding, managerial role.

The OSO contacted the insurer, asking them to consider that a job as an office manager of a busy firm could not be equated with a home business. He also suggested that the medical evidence was clear that Ms. V.’s condition had not changed between the last day of paid benefits and the first day of denied benefits.

Upon further discussion and review, the insurer agreed and provided Ms. V. with payment for the period that correlated with her inability to perform the essential duties of her job.

An illness or a symptom? (disability)

Posted on: February 2, 2016

Ms. C. had been suffering from chronic migraines and headaches for years, exacerbated by depression and anxiety. She was being actively treated for her conditions. When her loss of concentration began to negatively impact her work product, coupled with her inability to physically sit in front of a computer, she went on short term disability (STD). The insurer denied her claim, citing insufficient clinical medical evidence to support an ongoing condition. The insurer felt that Ms. C. was well enough to work and, upon her appeal, upheld its decision to deny STD.

Ms. C. approached OLHI for an independent, impartial review. The Dispute Resolution Officer (DRO) went through Ms. C.’s records, medical notes from various doctors and specialists, as well as the insurer’s file. He also read a letter from her employer, who verified that Ms. C.’s inability to work and cope with her migraines had negatively impacted the business – and precluded her from performing her regular duties.

The DRO recommended that an OmbudService Officer (OSO) investigate Ms. C.’s case. Upon further review, the OSO focused on a statement the insurer made in its final decision, classifying Ms. C.’s migraines, headaches and depression as “symptoms” lacking a specific medical condition. Ms. C. and her doctors stressed to the insurer and to the OSO that her diagnostic tests (x-rays, CT scans, blood work) were normal/negative to rule out symptoms of a secondary illness, such as tumours – not to rule out her condition.

The OSO agreed that migraines and depression are an illness and not symptoms of another unknown, unsupported condition. Her doctor provided examples from various credible sources, including the World Health Organization, confirming that migraines and depression are illnesses.

OLHI recommended that the insurer reconsider their position and pay Ms. C.’s STD claim.

The insurer, upon further reflection, agreed and provided payment of Ms. C.’s STD benefits.