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

Mr. T. contacted OLHI to seek assistance with reinstatement of his retirement group life insurance benefit. The Dispute Resolution Officer who took the call learned that this benefit had been allowed some years ago as part of an early retirement package negotiated with his employer. The employer was a life and health insurer, and OLHI Member Company.

OLHI learned that all had proceeded smoothly for several years until Mr. T.’s former employer sent him a letter which he did not receive because it was mailed to an out-dated postal address. This letter contained a notice advising the consumer that a medical certification of total disability was required to maintain his life insurance benefit. That letter was followed by another from his former employer, a month later, advising that his life insurance benefit had been cancelled for lack of the required medical certificate. This second letter was sent to Mr. T.’s current address.

OLHI was told that Mr. T. had immediately called his former employer to address the situation, at which point he learned that the letters had been sent to different addresses because separate databases had been used to locate his contact information. As it turns out, the database used to send the first notification letter had not been appropriately updated. Upon learning of this administrative glitch, Mr. T. sought written confirmation that his life insurance benefit would continue as part of his retirement package. Much to his dismay, several months later, the company confirmed that it would not continue the benefit on the basis that there was no commitment to do so.

Fortunately, Mr. T.’s former employer elected to treat the situation as an insurance matter, rather than an employment issue. As a result, it provided Mr. T. with a “final position letter,” inviting him to contact OLHI if he was dissatisfied. As is customary, the insurer’s final position letter provided OLHI’s contact details and a brief explanation of OLHI’s independent role in assisting life and health insurers and consumers to resolve their differences.

Following the conversation with Mr. T. and a review of the insurer’s final position letter, it was decided that the facts of the case warranted further investigation by an OLHI OmbudService Officer (OSO). The OSO reviewed the information collected to date and then spoke at length with the consumer. He ascertained that the agreement to provide Mr. T. with early group retirement benefits had indeed been made some years ago and that it was an oral commitment made with his employment superiors of the day. The consumer was very concerned because he now believed himself to be uninsurable and because some of the subscribers to the original agreement were no longer with the company.

Subsequently, the OSO prepared a written submission to the consumer’s employer, setting out the facts and issues as he understood them. He suggested that, although there was no written confirmation on the part of the company to provide Mr. T. with retirement group benefits, the fact that coverage had been provided for many years was evidence of that commitment. It was suggested that the commitment could not be voided by a notification error for which the consumer was not responsible.

In due course, the consumer’s employer replied, advising that it had reconsidered its original position and had arranged with the employer’s group benefits insurer to reinstate the consumer’s group life insurance benefit. As before, the life insurance benefit was subject to ongoing medical certification of total disability.

The employer thanked OLHI for bringing the issue of conflicting address databases to its attention and confirmed that it had undertaken an internal review of its employee address records. This review resulted in the company changing its policy on record keeping practices for employee addresses so that problems of this nature would not occur in the future with Mr. T. and other current or former employees.

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. S. called OLHI in early 2012. The Dispute Resolution Officer (DRO) who took the call learned that he was currently 61 years of age and had worked as horticulturist all his life until four years earlier, when he hurt his back. He was unable to work since the injury and had been declared “totally disabled” by the Régie des Rentes du Québec (“RRQ”). To obtain benefits from the RRQ, Mr. S. was required to demonstrate that he had a “severe and permanent disability.”

The consumer owed $20,000 in principle under his mortgage. Following his injury, his insurer covered his monthly mortgages under the credit insurance he purchased when he took out his mortgage. This insurance provided that, in the event of disability, the insurer would pay 150% of all mortgage related expenses. This meant that in addition to covering 100% of the monthly mortgage payments, Mr. S. received an additional 50% for other mortage related costs such as home insurance, realty taxes, etc. Monthly premiums on Mr. S.’s credit insurance were also waived. After 12 months, however, the insurer stopped all payments and Mr. S. was charged his monthly credit insurance premiums.

Mr. S. approached OLHI seeking to have his mortgage paid off in full. He believed this was appropriate because he was certified as being “totally disabled” by the RRQ in 2008. His medical condition had not improved since that date and he thought he was unable to work at any occupation.

Our DRO explained that it was typical that disability benefits would be paid for an initial period (in this case 12 months) based on inability to perform one’s own occupation. However, after that period, Mr. S. would need to demonstrate that he was unable to perform any occupation for the benefits to continue. She further explained that the RRQ’s determination that he was totally disabled did not necessarily prove that he was “unable to perform any occupation,” the standard for receiving benefits under the policy.

The DRO advised Mr. S. that before accessing OLHI’s complaint process, he would first have to complete the insurer’s internal complaints process. She suggested he write the insurer and formally ask for a review of his file, including all the facts he had shared with OLHI.

Approximately a month later, Mr. S. called OLHI again and advised he had received a call from the insurer offering to pay off a portion of the mortgage debt. He did not understand on what basis the amount was offered or whether the insurer had accepted his disability. Our DRO suggested Mr. S. submit his outstanding questions to the insurer and consider making a counter-offer.

Several months later, Mr. S. called our DRO to update her on the matter. He reported that over the preceeding months he and the insurer had a series of discussions. Several offers and counter offers were made on both sides. Eventually, his complaint was escalated through the insurer’s internal complaint process to its Ombudsman. In the end, the insurer agreed to pay the consumer’s $20,000 mortgage in full. In exchange, Mr. S. agreed to waive his entitlement to payment of the additional 50% benefits under the contract and to forgo reimbursement of the credit insurance premiums.

Mr. S. was pleased that he no longer had to worry about making his mortgage payments, given his age and inability to work, and thanked our DRO for her assistance in explaining how to proceed through the insurer’s complaint process.

 

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.

Ms. F. called OLHI on behalf of a member of her family, Mr. L., to seek assistance with reinstatement of disability benefits that had been discontinued under his group policy. Mr. L. could not act for himself due to his state of disability. The OLHI Dispute Resolution Officer (DRO) learned that short-term disability benefits had been paid for a period of six months. Long term disability benefits were paid, on a trial basis, for a year and were then discontinued following an independent medical examination conducted on behalf of the insurer.

In sum, based on the medical examination, the insurer suspected that the insured was feigning his disability. The insurer also queried whether Mr. L. met the condition of “total disability” as per his insurance contract. Ms. F. called OLHI seeking assistance with the reinstatement of benefits. The complaint was initially reviewed by a DRO and was then referred to an OmbudService Officer (OSO) for a more detailed examination.

As is usual, Mr. L.’s group disability plan provided benefits for a period of 24 months if a claimant can demonstrate disability from his or her own pre-disability occupation. In order to qualify for benefits after that period, the claimant must provide evidence to support his or her inability to perform any occupation for which he is reasonably suited by education, training or experience.

OLHI’s OSO reviewed the extracted documents from the claims file previously provided to Ms. F. by the insurer. He then spoke at length with her to ascertain the chronology of events and the extent of her involvement to date. Taking into account the information already available, he determined that this case would best be served by a review of the insurer’s claim file. The insurer readily agreed and cooperatively provided the complete claim file.

A review of the insurer’s claim file and the additional information provided by the insured’s representative disclosed that Mr. L. had subsequently left his minimum wage-type work in the hospitality industry in order to be closer to his family. The file also revealed a history of progressively worsening mental health, culminating in Mr. L.’s hospitalization by the time of the OSO’s review.

The OSO appreciated the reasons for the insurer’s concerns about proof of disability, which were based on anecdotal evidence that suggested Mr. L. was physically active and had made some efforts to find a job. However, our Officer’s review of the claim history led him to conclude that the insured was indeed suffering from a serious deteriorating mental disability. This disability had not been clearly diagnosed at the time of the insurer’s decision to terminate benefits but had been conclusively diagnosed by the time OLHI’s Officer was reviewing the case.

Upon conclusion of his review, the OSO made a detailed written submission to the insurer. He acknowledged the insurer’s concerns and the fact that this was a challenging and complex claim. However, his view was that the evidence did not support a conclusion of feigning on the part of the insured. He suggested that the totality of the subsequent circumstances, which indicated a progressive deterioration in mental health, also be taken into account.

Upon receipt of our Officer’s analysis, the insurer referred the case back to its business unit for further consideration. In due course, the insurance company offered Mr. L. a lump sum settlement or reinstatement of the claim back to a point in time where the insurer accepted that Mr. L. was unquestionably totally disabled from any occupation. This offer was considered fair by OLHI’s OSO and the reinstatement of claim option was eventually accepted.

 

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. 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.

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.

Mr. G. went on a medical leave from work for a year, due to a mood disorder that included depression. During this time, through his group insurance plan, his employer covered his disability benefits. But after a year, the insurer terminated benefits upon receiving information from Mr. G.’s doctor that he was planning on returning to work. He did not, though, as his psychiatrist stated that he was unable to. The insurer completed a medical investigation and, in its final position letter, wrote that Mr. G. was not completely disabled and could return to work.

Mr. G. contacted a Dispute Resolution Officer (DRO) at OLHI. The DRO discovered that while Mr. G’s doctor had recommended he return to work, his psychiatrist did not support the finding and felt that Mr. G. was still suffering from a severe disorder. For this reason, the DRO recommended the complaint be escalated to an OmbudService Officer (OSO) for investigation.

As a part of his review, the OSO spoke with the consumer as well as the insurer and went through all the documents that both parties shared with him. The medical reports revealed that even after his disability payments stopped, his psychiatrist continued to treat Mr. G. for his illness. The OSO also discovered a crucial detail: that the insurer’s decision to stop disability payments was based on a conversation with Mr. G.’s psychiatrist, where he said Mr. G. had quit his job. However, the transcript of this telephone conversation did not match formal reports. Mr. G. explained to the OSO that his psychiatrist may have confused the fact that he quit another job many years earlier.

The OSO reached out to the insurer, requesting they confirm with the employer whether Mr. G. had in fact quit or was still employed and on leave. The employer was able to confirm that he had not quit his job. After some further discussion, the insurer agreed to reconsider and made a settlement offer. Mr. G. was thrilled to reach a settlement and was also very appreciative of the way the OSO was able to explain his case in plain language to him so that he could better understand how the insurer reached their initial decision.

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.