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

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.

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.