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

Submitting claims after you leave a job (health)

Posted on: March 2, 2017

Ms. P. stopped working for her employer in April. For the next 90 days (until July), her employee benefits plan would accept any health expenses incurred before her last day of employment.

Before she stopped working, Ms. P. saw a health practitioner. He sent a claim submission to the insurance company twice: once in April and, when she didn’t get her claim paid, he sent it again in May at her request.

In August, the insurance company received the expense claim. It was declined because more than three months had passed since Ms. P. stopped working. They suggested that, if dissatisfied, she could seek an independent, free review of her case from OLHI.

Ms. P. explained to OLHI’s Dispute Resolution Officer (DRO) that she had spoken with the insurance company’s call centre in August. She was told that so long as she submitted her paperwork that month, she would get paid. Based on this information, the DRO recommended the case be escalated to an OmbudService Officer (OSO).

Investigating records from Ms. P. and the insurance company, the OSO found some discrepancies: the health practitioner said he sent documents in April and May but there was no evidence that the company received anything until August. The call centre recording revealed that the agent had incorrectly assumed that Ms. P. stopped working in May and that, based on this date, she had until August to submit her claim. Ms. P. did not correct the date, nor did the agent promise she would be paid.

The OSO determined that there was no hard evidence that the health practitioner had submitted a claim to the insurance company before the three months had ended. He also found that the call centre agent had provided the correct advice about the three-month period after an employee stops working – but he just used the wrong timeline, which was not corrected by Ms. P. Details about the claim period were also clearly outlined in the benefits booklet that Ms. P. received when she was hired.

For these reasons, OLHI’s OSO recommended that the insurance company’s decision be maintained.

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.

Going the distance (health)

Posted on: June 16, 2016

Mrs. O. had lung cancer and lived in a small, remote area of her province. She needed radiation and chemo therapy and chose to go to a city about 400 kilometres away. Her provincial health care plan reimbursed her for travel and lodging expenses if she had to consult a specialist outside her region. Her group health insurance policy, through her employer, reimbursed her for the rest of what the provincial plan did not cover.

When Mrs. O. submitted her claim, her employer’s insurance company declined it. They said she should have gone instead to a hospital that was closer to her home by 30 kilometres than the other hospital she went to. The insurance policy required that she travel to the closest hospital.

Mrs. O. brought the final position letter to OLHI for a free, independent review of the case. She told our Dispute Resolution Officer (DRO) that traveling to the other hospital would have taken longer in travel time, even if it seemed closer from a distance perspective. She also said she chose the hospital she went to because her specialist was affiliated with it.

OLHI’s DRO reviewed all the information provided by Mrs. O. and by the insurance company. He discovered that the insurance policy carefully outlined reimbursement if a specialist was located more than 200 kilometres away from the person’s home, so long as the specialist was as close as possible to the person. Proximity was based on kilometres, not travel time. The DRO also learned that the provincial plan had declined reimbursement for the same reason.

After thorough review of the policy and discussions with Mrs. O., OLHI explained what the policy said and why Mrs. O. was not able to be reimbursed. The DRO also explained that, for this reason, OLHI believed that the insurance company had made the proper decision.

Hidden history (health)

Posted on: June 16, 2016

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.