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.