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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.

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.

 

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.

Mrs. E.’s employer provided everyone in her company with extended health care coverage through a group plan. The plan reimbursed her for 80% of her drug costs, with no limit on cost or any other limits. On her 75th birthday, her company benefits would end.

When she was 35, Mrs. E. was diagnosed with a severe liver disease. Her doctor, the leading Canadian specialist in this disease, prescribed Drug A, which costs more than $500,000 per year. It was clear that Mrs. E.’s condition would require life-long treatment.

For the first three months, Mrs. E. was reimbursed for the drugs. Afterward, the insurance company told her that another drug (Drug B) was available for free through a special provincial drug plan that covered expensive therapies. The insurance company declined her future coverage for Drug A.

Mrs. E. appealed this decision. The insurance company’s Ombudsman recommended that the claims department speak with her doctor. This doctor told them that Drug A was prescribed only because he did not want to burden the public plan with the cost of the medication, since Mrs. E.’s group plan provided ample coverage. In its’ final position letter, the insurance company declined payment, explaining that there was no reason why Mrs. E. could not take the free Drug B. The company told Mrs. E. that if she was not satisfied with the decision, she could ask OLHI for an independent, impartial and free review of the case.

Not long after, OLHI received a request to become involved. Our Dispute Resolution Officer (DRO) carefully reviewed the insurance policy, noting that there were no limits on the dollar amount for drug claims and there were no other limits or exclusions. Going through the insurance company’s files, he saw a comment from the company’s Ombudsman noting the same things and suggesting that the claims department reconsider the denial. The DRO recommended this be escalated to an OmbudService Officer (OSO) for further review, particularly because he was unsure about whether Mrs. E. would even qualify under the special provincial plan.

OLHI’s OSO discovered that Mrs. E. could get full coverage for not only Drug B but also for Drug A through the provincial plan. As a result, the insurance company did not have to continue paying for her treatment.

 

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. A. called OLHI seeking assistance with her group health benefits. Her insurer had denied payment for treatments recommended for her son’s cerebral palsy and issued her a letter referring her to OLHI if she wished to further pursue her complaint. All Canadian life and health insurers who are members of OLHI issue such a letter, known as a “final position letter,” once their internal company complaint process is completed.

Based on their conversation, the Dispute Resolution Officer (DRO) concluded that OLHI could proceed with an independent review of Mrs. A.’s complaint once she had signed and submitted OLHI’s Authorization form. A letter was then sent to Mrs. A. confirming that the complaint had been opened and she could expect to hear from OLHI within 60 to 90 days. Copies of all documents relevant to the complaint were requested from both Mrs. A. and her insurer, including her employee benefits brochure and all relevant correspondence.

The documents submitted by both parties were reviewed by the DRO. He noted that the definition of “eligible expense” in the insurance policy and in the benefits brochure contained several conditions. Nevertheless, he was not convinced that the terms of the insurer’s policy clearly explained why and how the claim was not eligible. He noted that conflicting messages may have been given by the insurer. Accordingly, he recommended that the complaint be escalated to an OLHI OmbudService Officer (OSO) for further review.

Upon receipt of the complaint file, the OSO reviewed the proceedings to date, including the documents from both parties. He then spoke at length with Mrs. A., who had been left confused by the insurer’s communications.

He learned that initially, Mrs. A. was told the treatments would be covered. She was then advised, in writing, that the proposed treatments were not eligible because they were not considered “reasonable,” although the insurer offered to reconsider its’ position if she could demonstrate that the treatments were medically supported. Based on this information, Mrs. A. obtained a letter from her son’s doctor justifying the treatments but the insurer denied the claim once again.

In the meantime, a representative of the insurer had mentioned to Mrs. A. that treatments of this nature had been previously allowed on an individual basis.

The OSO contacted the insurer to gain a better understanding of its’ position. In particular, he wanted to understand why Mrs. A.’s claim had been turned down after she had submitted medical evidence that, on its face, seemed to prove that the treatments were medically reasonable. He was told that the proposed treatments were not eligible for payment because the relevant section of the policy was intended only to cover the cost of medical equipment, not the treatments themselves.

A further review of the insurer’s claim file by the OSO disclosed that the position that only medical equipment was covered had surfaced after the insurer had advised Mrs. A. in writing that “medically reasonable” treatments would be paid.

The OSO then made a detailed submission to the insurer. He recommended that, in light of the lack of clarity in the policy wording and the insurer’s conflicting and confusing messages to the consumer, it might consider allowing the claim without recourse to the experience-rating of the policy.

The insurer agreed to do so, and the course of treatments was allowed.

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. 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.

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.

Mr. R. e-mailed OLHI because he was experiencing difficulty with the administration of his extended health care claims. He had an individual health insurance plan with Company A and he was also covered under his spouse’s group insurance plan with Company B.

For many years, he had submitted his health claims first to his individual plan, Company A, and then filed claims under his spouse’s group plan, Company B, for any residual expenses not covered by the individual plan. However, he was now being told by Company A to first submit his claims to his wife’s group plan. Mr. R. complied with this directive but Company B also refused to take responsibility as first payer. When he advised Company A of Company B’s response, Company A told him to sort the problem out himself.

As background, the health and dental benefits industry has developed a Coordination of Benefits (COB) Guideline that describes the order in which benefits are determined and how to coordinate health care or dental payments from all available group plans. Although there is no guideline prescribing the order in which benefits are determined for individual plans, there is a general consensus in the industry that group plans should be first payers. Company A was relying on this unwritten rule when it asked Mr. R. to file his claims with his wife’s group plan first.

The situation was further complicated by the fact that the group carrier, Company B, was not an OLHI member company and thus our Dispute Resolution Officer (DRO) was unable to open up a dialogue with Company B on Mr. R.’s behalf. By way of explanation, although all federally incorporated life and health insurers are required to belong to an independent complaint resolution service and most choose OLHI due to our expertise in the field, provincially incorporated life and health insurers are not subject to this requirement, although many do choose to become OLHI members.

In an effort to work out a solution, OLHI’s DRO wrote to Company A’s Complaints Officer pointing out that it did not appear fair that Mr. R. should be disadvantaged or expected to sort out the problem himself, but OLHI could not approach Company B as it was a non-member insurance company. Our DRO suggested that Company A should contact Company B directly on behalf of its policyholder to bring about a mutually agreeable resolution.

That same day, Company A responded. It agreed with our DRO that Mr. R., as their policyholder, should not be disadvantaged by these circumstances or required to sort through the issue himself. Company A further confirmed that it would resume responsibility as the first payer of his claims, in recognition of the problems he was encountering with Company B.

Mr. R. was understandably pleased that OLHI was able to have facilitated a settlement that ensured both insurance companies would resume administration and payment of his health benefits claims, as opposed to neither processing and paying his expenses.

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.