An elderly man named Fred fell and went to hospital with a head injury. He was discharged the next day. His son cared for him at home.
Soon after, Fred had headaches and bouts of vomiting and returned to hospital. When he was discharged a month later, he moved into long-term care as he was unable to walk.
Fred asked his son to submit an accident benefits claim on his behalf to pay for his medical expenses.
Fred’s insurer denied the claim. His son appealed, but the company upheld its final position.
When Fred’s son received the insurance company’s final position letter, he came to OLHI for help.
OLHI’s complaints team reviewed the complaint. We discovered that the original accident benefits claim did not have all of the available information about Fred’s injuries and hospital stays.
Based on hospital records, it was clear that both of Fred’s hospital stays were a result of his fall.
OLHI recommended that the insurer reconsider covering Fred’s hospital expenses.
The insurer paid the claim because of this new information.
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.