pre-existing condition | OLHI - OmbudService for Life & Health Insurance | Resolution of your Canadian Insurance Concerns | OLHI

OLHI OLHI – OmbudService for Life & Health Insurance | Resolution of your Canadian Insurance Concerns | OLHI

Mrs. T. purchased medical travel insurance ahead of a trip abroad. On that holiday, she fell ill and had to be treated in hospital. Afterward, she submitted her claim. It was declined because the insurance plan did not cover anyone who had been treated for three specific medical conditions. In its final position letter, the insurance company wrote that Mrs. T. had been treated for these conditions.

Mrs. T. contacted OLHI, asking for a free, independent review of her case. She told our Dispute Resolution Officer (DRO) that she had been diagnosed and treated for two of the medical conditions. But she had never been diagnosed or treated for the third condition: hypertension/high blood pressure.

OLHI’s DRO asked Mrs. T. and her insurance company to provide all their information relating to this case. In his review, he found that Mrs. T. was taking a medication for stroke management. The medication prescribed is also used to treat blood pressure. However, this was not the reason why it was prescribed for Mrs. T. In her case, it was for stroke management.

The DRO recommended that the case be escalated to an OmbudService Officer (OSO) for further investigation. Looking at all the files, the OSO read that Mrs. T.’s doctor had confirmed with the insurance company that she had never been diagnosed with high blood pressure. Although it was acknowledged that this particular medication is often prescribed for hypertension, Mrs. T. was taking it to control her history with strokes – and not hypertension/high blood pressure.

The OSO reached out to Mrs. T.’s insurance company and recommended they revisit the case. Because of a history of strokes, controlling blood pressure was necessary but it did not mean that she was hypertensive. The insurance company agreed with the OSO’s suggestion and paid out Mrs. T.’s claim for her hospital 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.

 

Ms. E. had extended health insurance through her employer. She disclosed that she suffered from seizures. This insurance also covered out-of-country emergency medical expenses. While on vacation, Ms. E. became ill and was hospitalized. Doctors determined that she had a bad reaction to a drug she was taking to treat a pre-existing condition. While in hospital, Ms. E. became worse due to an unrelated illness and had to return to Canada immediately.

The insurance company covered the costs of Ms. E.’s transportation back home to continue her care. However, in their final position letter, they stated they would not cover treatment for her reaction to the drug. The company decided that Ms. E.’s pre-existing condition extended to any side effects from medications taken for this condition.

Ms. E. asked OLHI to become involved. She told our Dispute Resolution Officer (DRO) that she believed her insurance company was setting a bad precedent. She said their decision could lead to denying coverage to any person on medication who suffers a side effect. For example, Ms. E. questioned what would happen if a person has a bad side effect from an over-the-counter pain reliever. Could the insurance company refuse to cover treatment, if this pain reliever treats a pre-existing condition?

The DRO recommended that an OmbudService Officer (OSO) investigate Ms. E.’s case. The OSO learned that a doctor saw Ms. E. when she returned to Canada. The doctor felt that it could not be proven with certainty that the Ms. E.’s problems were side effects of her medication. He suggested that her problems could have been caused by the unrelated illness she had after she was hospitalized.

The OSO contacted the insurance company’s Ombuds office. He advised that Ms. E.’s policy did not specify that it would not cover side effects from a medication. He also reinforced the fact that there was uncertainty around what caused Ms. E.’s illness. This made it impossible to tell, conclusively, that her treatment was for her pre-existing condition. He recommended that the insurer reconsider its position and pay Ms. E.’s claim.

The insurer, upon further reflection, agreed and provided payment on the out-of-country medical 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.

Mr. O.’s travel insurance application declared that he was suffering from chronic lower back pain from a fall in 2008. His insurance application was approved, with the pre-existing condition noted. While on holiday, he suffered acute hip pain and, as advised by the insurer, was taken by ambulance to a hospital where he was tested, treated with pain killers and released.

The insurer denied Mr. O.’s claim on the grounds of his pre-existing condition and that he had not reported a steroid injection treatment he received days before his vacation.

Mr. O. appealed the denial, following the insurer’s complaint process. The insurer upheld its’ decision so Mr. O. submitted his complaint to OLHI for review.

Through a review of both the consumer’s and insurer’s documents, the Dispute Resolution Officer (DRO) narrowed the issue down to the insurer’s position that the hip pain was directly related to the steroid injection before his trip. Although the DRO agreed that Mr. O. should have reported the treatment before his trip, she also agreed with his doctor’s view that, given the time between the treatment and the hip pain, there was no direct cause and effect. She suggested that the complaint be escalated to an OmbudService Officer (OSO) for further investigation.

The OSO reviewed the file and also spoke with the consumer. He raised two issues: 1.) Was the hip pain that triggered the hospitalization a pre-existing condition, as defined by the policy; and    2.) Did the injection just before travelling directly contribute to the hip pain? The OSO found that, although Mr. O.’s doctor challenged that the injection caused the hip pain, clinical notes from both the doctor and the hospital’s attending physician supported the insurer’s position that the hip pain was most likely due to the consumer’s chronic lower back pain.

The OSO felt it was unlikely that he could argue that the hip pain was not part of the defined pre-existing condition. He also determined that Mr. O.’s failure to notify the insurer of the injection had deprived the insurer of the opportunity to determine if the injection was a material change to the assumed risk – thereby potentially permitting the insurer to decline coverage.

The insurer’s claim denial was 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.

Mr. Z. purchased out-of-Canada emergency medical expense insurance in connection with a trip to the U.S. While there, he needed medical treatment for a kidney stone and, afterward, submitted a claim to the insurer for the expenses he incurred.

The claim was denied because his U.S. hospital records noted that he had experienced flank/back pain a week before his departure and he had not disclosed this to his insurer before traveling.

The exclusions section of his policy denied coverage for any sickness, injury or medical condition, occurring before the date he left on his trip, which was expected to lead to treatment or hospitalization. In sum, the insurer believed that Mr. Z. had a “pre-existing medical condition” that he was required to tell them about before traveling. All travel insurance contracts contain a clause of this nature; however, the exact disclosure requirements vary from contract to contract.

Mr. Z. appealed the denial and followed the insurer’s complaint process, where the decision was upheld by the insurer. He then submitted his complaint to OLHI for review.

With both the details provided by the consumer and the insurer’s file in hand, OLHI’s Dispute Resolution Officer (“DRO”) reviewed the case and concluded that the denial was entirely based on statements contained in the U.S. hospital records regarding prior back/flank pain. The DRO found that there had been no contact initiated by the insurer with either the U.S. hospital or the consumer. He also observed that the U.S. hospital notes stated that the consumer had experienced pain one week prior, that went away, and, in direct contradiction, that Mr. Z. had experienced “unremitting flank/back pain” for the entire week prior to his departure.

Although the insurer’s Ombudsman had suggested that the claim be paid, the business unit declined the claim.

OLHI’s DRO expressed doubt about the accuracy of the U.S. hospital records and suggested that this could be the basis for OLHI to approach the insurer. It was recommended that the complaint be escalated to an OLHI OmbudService Officer (“OSO”) for further investigation.

The OSO spoke with the consumer directly and learned that he had made no mention whatsoever of any “flank pain” but that the back pain he had experienced one week prior to departure went away on its own with over-the-counter pain relief and a warm bath. Our OSO also reviewed the documents provided by the insurer, including the insurer’s claims review process documents. His findings echoed those of the insurer’s Ombudsman.

In his submission to the insurer, the OSO highlighted the incongruities in the U.S. hospital records. He suggested that the policy exclusion could not be fairly invoked given the fact that Mr. Z.’s prior back pain had gone away with a warm bath and an over-the-counter pain reliever. He also suggested that it was improbable that anyone with constant, severe pain leading up to this trip could travel anywhere and hence the unreliability of the U.S. hospital admission record. The OSO recommended that the insurer reconsider its’ decision.

The insurer thanked the OSO for his comprehensive review and supported OLHI’s recommendation to pay this claim. The consumer‘s claim was paid shortly thereafter.

 

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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