ombudservice for life and health insurance – OLHI – Free, impartial help with your life & health insurance complaints

OLHI held its annual general meeting and released its annual report for 2016/17, reporting on a year of record numbers and renewed priorities.

Highlights:

  • Complaint volumes increase by 23.2% across Canada, marking a historic high
  • Increase in complaints from Quebec (+36.2%), Prairie provinces (+25.6%) and British Columbia (+ 24.4%)
  • Public contacts exceed 87,000
  • Edmonton office established as a part of western expansion strategy

Read the news release.

Mrs. R. frequently traveled out of country. She purchased a travel health insurance plan that would cover her for 35 days every time she left Canada. She departed in February and in May, while still on her holiday, she suffered a major illness, was hospitalized and passed away two weeks later.

While Mrs. R. was in hospital, her son, Mr. R., became involved. When he and the doctors reached out to the insurance company, the company confirmed that it would be able to help. Mrs. R. was transferred from one hospital to another for specialized care – a transfer that the company helped coordinate.

The insurance company denied the claim because the policy’s coverage had expired. In its final position letter, the company told Mr. R. about how OLHI reviews matters that consumers have not been able to resolve with their company. He contacted OLHI and asked a Dispute Resolution Officer (DRO) to become involved.

Mr. R. told the DRO that the company confirmed several times that his mother would be covered by the policy. He had no idea that her coverage was for only 35 days because he did not find this out from the company until after incurring costs.

Because of the complexity of the complaint, the DRO recommended that an OmbudService Officer (OSO) become involved to further delve into the investigation and to determine whether there were grounds for conciliation.

The OSO reviewed documents provided by all parties. He also listened to the recordings of telephone calls between Mr. R. and the company, as well as between the hospital and the company. In these calls, the company said that it would help with the hospital transfer but that it was not a guarantee of coverage because the claim still had to be processed and reviewed for approval. In those conversations, the company did not yet know when Mrs. R. had left on her out-of-country trip.

The OSO recommended that there were no grounds to pursue. The company’s claims process included confirming the coverage period. He also agreed that while the company said that Mrs. R. had insurance coverage, it also said that her claim still had to be reviewed to confirm she met the policy’s terms of coverage.

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. C. worked as an office administrator, a predominantly sedentary role. She began to experience medical conditions that affected her back. Her employer’s group disability insurance plan covered her short-term disability claim. After several months, the insurance company denied Ms. C.’s coverage for long-term disability (LTD), stating that her illness did not prevent her from performing her job. The final position letter explained that Ms. C’s illness lacked clinical medical information to satisfy the terms of the disability contract.

After receiving this letter, which pointed to OLHI as an independent dispute resolution service, Ms. C. approached OLHI. In her review, OLHI’s Dispute Resolution Officer (DRO) noted that medical reports determined Ms. C. was not fit for work and that her condition was deteriorating. Meanwhile, the insurance company interpreted the reports differently, finding there was an improvement in her condition. The DRO also questioned whether the insurance company was relying too much on looking for neurological evidence that did not directly correlate with Ms. C.’s diagnosis from her doctor and specialist.

With these questions in mind, the DRO recommended an OmbudService Officer (OSO) further investigate Ms. C.’s complaint.

OLHI’s OSO learned that the tests conducted on Ms. C. returned with negative or mild/moderate results. Medical reports recommended that she could still perform sedentary or light duties, fitting with her job description, and her doctor supported a gradual return to work program. However, Ms. C.’s employer declined the program and instead ordered an independent medical examination, which concluded that she was not fit to work. Meanwhile, other conflicting medical reports suggested that Ms. C.’s condition was deteriorating because of an unhealthy lifestyle and not because of her diagnosis affecting her back.

Given the conflicting information and the employer’s refusal to have Ms. C. return to work because of its own medical findings, the OSO recommended that the insurance company and the employer reach an agreement. With OLHI’s recommendation, Ms. C. was able to reach a settlement.

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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