pre-existing - 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. 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.

Mr. M. called OLHI after he received a letter from his wife’s insurer turning down her travel insurance claim. He and his wife had purchased out- of- country emergency medical and hospital insurance to cover them for an upcoming trip to the U.S. The insurance was bought over the phone and medical questions answered orally by both Mr. M. and his wife.

Unfortunately, Mrs. M was admitted to hospital and underwent emergency heart surgery while on vacation. When she returned home, she submitted a claim to the insurer for her U.S. medical and hospital expenses. These expenses were significant as Mrs. M. had spent over two weeks in hospital. The insurer denied payment for the claim on the basis that Mrs. M. had failed to fully disclose her medical history. Mr. M. contended that his wife had disclosed all necessary medical issues.

Since the insurer had issued its final position letter, our Dispute Resolution Officer (DRO) advised Mr. M. that OLHI could open a complaint file to determine if there were grounds to review the insurer’s decision. To start the process, Mrs. M. was asked to sign and submit OLHI’s standard Authorization form and all relevant documents, including a copy of the insurer’s final position letter.

During the initial call to OLHI, Mr. M. asked if his wife’s claim was subject to a “limitation period” – that is whether there was a time limit to start a legal action against the insurer to recover his wife’s expenses. He was told that the running of the limitation period was suspended while his complaint was under review by OLHI. He was advised to consult a lawyer if he had any concerns about what limitation period applied to his wife’s claim since OLHI could not provide legal advice.

In accordance with industry standard practice, once Mrs. M. filed a claim, her insurer obtained copies of her medical records. These records were provided to the insurer pursuant to a written consent signed by Mrs. M. at the time she filed her claim. The insurer forwarded copies of these medical records to OLHI once Mrs. M.’s complaint file was opened.

Upon reviewing Mrs. M.’s medical records, our DRO learned that Mrs. M. had seen her family doctor on three occasions just before she bought her travel insurance. These visits were made to address complaints of chest pain. A follow up test booked by her physician to investigate the symptoms was cancelled by Mrs. M. until she returned from her vacation. However, when she bought her travel insurance, Mrs. M. had told the insurer that she had not seen a doctor for “any reason that was not routine within the last 12 months”. In sum, the insurer had turned down Mrs. M.’s claim for reimbursement of expenses because she was under investigation for a pre-existing medical condition within that period.

Mrs. M.’s position was that the three visits she made to her doctor were in connection with a “minor ailment”, which was permitted under the policy. She argued that she had no “pre-existing medical condition” nor were her visits to the doctor made in connection with such a condition. The policy defined “minor ailment” as one that did not require more than one follow-up visit with her physician.

OLHI’s DRO concluded that Mrs. M. did not have a minor aliment because her condition required two follow up visits. As a result, the “pre-existing conditions” clause of the policy applied. This meant that she was required to disclose her full medical history to her insurer, including any and all consultations with doctors for “non routine reasons” within 12 months.

In the final analysis, Mrs. M. did not disclose her full medical/health history when applying for travel insurance and the insurer had legitimately turned down her claim for payment. Mrs. M. was advised that there were no grounds for OLHI to review her complaint with the insurer and her OLHI complaint was closed.

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. A. contacted OLHI when he was denied reimbursement for a cancelled trip to the Caribbean. By the time he called, his request for payment had been turned down three times with the identical “form letter” and he was, understandably, frustrated. His frustration was exacerbated by the fact that his traveling companion had been reimbursed the cost of her cancelled trip many months before.

The OLHI Dispute Resolution Officer (DRO) who spoke to Mr. A. learned that in late September, he had booked a trip to the Caribbean for himself and his common-law wife, with a departure date in December. He paid for his trip on his credit card. One of the benefits afforded to holders of the credit card was automatic “trip cancellation insurance” that permitted card holders to be reimbursed if a trip paid for through the credit card was cancelled in certain circumstances. The specific clause permitted full reimbursement of the cost of the trip in the event of “the unexpected death, sickness, injury or quarantine of you, your immediate family member, your travel companion or your travel companion’s immediate family member. Sickness and injury must require the care and attendance of a physician and the physician recommends interruption of the trip.”

Unbeknownst to both Mr. A. and his common-law wife, her daughter had seen a physician in early September, before their trip was booked, with a general complaint of abdominal pain. The daughter was in her mid-20s, self supporting, and did not live with her mother and Mr. A. In fact, they had no idea that she had even visited the doctor until two months thereafter when test results arrived and the daughter advised them that her doctor recommended surgery to remove a cancerous growth. As is typical, the daughter was put on a waiting list for surgery “as soon as possible,” with no specific date. The daughter’s operation was eventually scheduled for a few days after Mr. A. and his wife were booked to fly to the Caribbean and hence they decided to cancel their trip.

Before cancelling the trip, Mr. A. called the claims administrator and obtained the forms required to submit a claim for reimbursement of his cancelled vacation. A file was opened and he promptly filled out and submitted both his form and the form required to be completed by the attending physician.

Approximately six weeks later, he received a response from the administrator of the claim denying his reimbursement application on the basis that “the cancellation of your trip is not covered by the terms of your insurance policy”.

Although he called the claims administrator several more times asking for an explanation why the claim was not covered, the company’s response was to issue two further letters with the same explanation. Eventually, he was told in a phone call that his claim was denied because his wife’s daughter had sought medical attention before he and his wife booked their trip.

Mr. A. did not understand this explanation because neither he nor his wife had any knowledge that the adult daughter had been to the doctor until her diagnosis was confirmed, several months after they booked their vacation. His lack of understanding was further compounded by the fact that his common-law wife, who had submitted a trip cancellation claim through her own insurance company, was reimbursed the cost of her trip within a month of submitting her claim.

Eventually, Mr. A. contacted OLHI. Our DRO recommended that he write to the manager of his insurer’s claim department, rather than continue calling the claims administrator. He wrote this letter but called OLHI back two months later when he had not received a response. At this point, our DRO wrote directly to the insurer’s Ombudsman, asking that Mr. A. be provided with a response to his letter. Within two days, the Ombudsman’s office replied to Mr. A. with a copy to OLHI.

It was finally explained to Mr. A. that his insurer was not willing to pay the claim because it did not consider the daughter’s condition to qualify as a “sickness” under the policy because it was not a “sudden illness or disease” since she had symptoms that caused her to see her physician before the trip was booked. This is a common interpretation by insurers, who take the view that any medical condition that is diagnosed after a trip is booked, but which is the subject of a doctors visit beforehand, is a pre-existing condition not covered under the travel insurance policy.

However, the good news for Mr. A. was that his credit card company agreed to reimburse him the full cost of his trip in any event, in view of the circumstances and the fact that he was a long standing and good customer.

 

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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