Ms. Z. had a sleeping problem and her doctor recommended she buy a piece of equipment that acted as a sleeping aid. After buying the equipment, Ms. Z. submitted a claim for reimbursement to the insurance company that provided health insurance through her employer’s group plan. The company denied the claim because “anti-snoring devices” were excluded under the policy.
Ms. Z. brought her final position letter to OLHI, where she spoke with a Dispute Resolution Officer (DRO). Ms. Z. told her that she had called the insurance company twice, telling them about the different devices that her doctor recommended and asking if each one was covered for sleep apnea. During each call, she was told that she was covered for these devices.
The DRO reviewed the insurance company’s policy and booklet wording. It clearly stated that anti-snoring devices were not covered although devices for sleep apnea were. The DRO also focused on the fact that Ms. Z. had asked about specific devices on each of her calls to the insurance company. For this reason, she recommended an OmbudService Officer (OSO) become involved.
The OSO reviewed the files from Ms. Z. and from her insurance company. The OSO called the company Ombudsman, who explained that Ms. Z.’s doctor had submitted a letter explaining that she was diagnosed with a snoring problem and not sleep apnea.
With this clarification, the OSO agreed that the claim was not payable because Ms. Z. had told the insurance company that these devices were for sleep apnea – something she did not have.
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.