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

Ms. Z. had a sleeping problem and her doctor recommended she buy a piece of equipment that acted as a sleeping aid. After buying the equipment, Ms. Z. submitted a claim for reimbursement to the insurance company that provided health insurance through her employer’s group plan. The company denied the claim because “anti-snoring devices” were excluded under the policy.

Ms. Z. brought her final position letter to OLHI, where she spoke with a Dispute Resolution Officer (DRO). Ms. Z. told her that she had called the insurance company twice, telling them about the different devices that her doctor recommended and asking if each one was covered for sleep apnea. During each call, she was told that she was covered for these devices.

The DRO reviewed the insurance company’s policy and booklet wording. It clearly stated that anti-snoring devices were not covered although devices for sleep apnea were. The DRO also focused on the fact that Ms. Z. had asked about specific devices on each of her calls to the insurance company. For this reason, she recommended an OmbudService Officer (OSO) become involved.

The OSO reviewed the files from Ms. Z. and from her insurance company. The OSO called the company Ombudsman, who explained that Ms. Z.’s doctor had submitted a letter explaining that she was diagnosed with a snoring problem and not sleep apnea.

With this clarification, the OSO agreed that the claim was not payable because Ms. Z. had told the insurance company that these devices were for sleep apnea – something she did not have.

 

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.

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.

 

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. 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.

 

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.

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