Mr. Q. wanted to buy new glasses through his employer’s group health insurance plan. Employees could only buy new glasses every two years – a standard period for many plans. He could not remember the last time he bought glasses.
Logging onto the insurance company’s website, Mr. Q. accessed his personal list of transactions made over the last two years. He did not see any purchase for glasses during this time so he bought new glasses and submitted his claim.
The insurance company denied Mr. Q.’s claim because he had in fact purchased glasses the prior year. They said that this claim was listed under the website’s section about “My Claims” – and not under “My Transactions.” They explained that there were two lists on their website: one for claims that an employee filed online (My Transactions) and one for claims that employees filed manually (My Claims). Because Mr. Q. had submitted his glasses claim last year manually, it did not show up on his list of “My Transactions.”
The insurance company suggested that if Mr. Q. was dissatisfied with the decision, he could contact OLHI for a free, impartial review. He brought his final position letter to OLHI and a Dispute Resolution Officer (DRO) started to review his case. Mr. Q. explained to the DRO that the insurance company’s website doesn’t direct people to look under both sections. Mr. Q. felt that a reasonable person would not think to check both places as a list of transactions implies all transactions ever made through his benefit plan.
OLHI’s DRO noted that Mr. Q. had a point: the website did not warn that an employee should look at both lists because each list showed a history of claims transactions depending on the way they were submitted. For this reason, OLHI contacted the insurance company and explained how confusing the process could be for an employee and how a mistake of this nature could be made.
The insurance company agreed to reimburse Mr. Q. for half of the cost of the glasses and he accepted this offer.
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.