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Fulfilling a policy (critical illness)

Disability

Mr. J. was diagnosed with prostate cancer and submitted a claim against his Critical Illness policy. His insurer declined his benefit, stating that his particular type of prostate cancer was at a stage that is not covered under his policy.

Mr. J. contacted OLHI with his insurer’s final position letter, telling our Dispute Resolution Officer (DRO) that his stage one cancer was on a list of exclusions – a list he never received from the insurer, so he was completely unaware of this detail. While Mr. J. did receive a one-page document outlining his schedule of coverage, he did not receive the complete policy package, known as the fulfillment kit, which would have also included a cover letter and detailed policy.

Upon further review by the DRO, he discovered that the insurer’s records confirmed that the fulfillment kit status was “pending print in print queue.” Based on this, there was reasonable doubt that Mr. J. did not get the kit. He recommended that an OmbudService Officer (OSO) investigate.

OLHI’s OSO agreed that it was reasonable for Mr. J. to assume that he was covered, just based on the one-page document of information he had.

Because this one page included Mr. J.’s address and did not reference any other documents, there was logic in Mr. J. believing this page formed his complete policy. In Ontario, by law, an insurer must deliver a policy to the insured and the insured has the right to review and agree to it. The OSO suggested that because Mr. J. did not get his fulfillment kit, he was deprived of his right to examine and agree to the complete policy.

As a result, the OSO contacted Mr. J.’s insurer and recommended they reconsider their decision, given the technical problem and reasonable doubt. As a gesture of good faith, the insurer agreed to pay out the claim.

 

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.