OLHI – OmbudService for Life & Health Insurance | Resolution of your Canadian Insurance Concerns | OLHI

Case Studies

Travelers health

Under pressure (travel)

Mrs. T. purchased medical travel insurance ahead of a trip abroad. On that holiday, she fell ill and had to be treated in hospital. Afterward, she submitted her claim. It was declined because the insurance plan did not cover anyone who had been treated for three specific medical conditions. In its final position letter, the

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casestudy1

An important conversation (life)

Mr. and Mrs. H. applied for life insurance and were approved. When her husband died several months later, Mrs. H. claimed the benefits under the policy. The insurance company denied the claim for failing to disclose information about Mr. H.’s health. Mrs. H. brought her final position letter to OLHI. She explained to our Dispute

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Businessmwoman computing on tablet pc

“Help” vs. “coverage” (travel)

Mrs. R. frequently traveled out of country. She purchased a travel health insurance plan that would cover her for 35 days every time she left Canada. She departed in February and in May, while still on her holiday, she suffered a major illness, was hospitalized and passed away two weeks later. While Mrs. R. was

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Medical Condition

Conflicting medical reports (disability)

Ms. C. worked as an office administrator, a predominantly sedentary role. She began to experience medical conditions that affected her back. Her employer’s group disability insurance plan covered her short-term disability claim. After several months, the insurance company denied Ms. C.’s coverage for long-term disability (LTD), stating that her illness did not prevent her from

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Woman lifting weight

Automatic renewal (life)

Mrs. U. purchased life insurance in 2006. She explained to her agent that she only wanted a policy that would cover her for 10 years and that she planned to cancel when the term expired. She said she would not be able to afford the new premiums, which would rise dramatically after 10 years. Mrs.

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Portrait of handsome Asian manager in his office

Contra proferentem (life)

When Mr. N. purchased life insurance in 2000, he explained to his agent that he wanted to pay the same monthly premium for the lifetime of the policy. His agent helped him fill out an application and also provided him with illustrations to show how his premium would never change. Fifteen years later, Mr. N.’s

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Senior women stretching arms on beach

Payouts for life (annuity)

In the 1980s, Mr. A. purchased an annuity so that he and his wife would have a monthly income over the course of their lives. When one passed away, the annuity would continue to provide income to the surviving spouse. Mr. A. passed away in 2015 and, after this, payments stopped. The insurance company’s final

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Medical Condition

Revisiting an old claim (disability)

Ms. H. was injured in a work-related accident. For around 10 years, she received long-term disability (LTD) payments through her employer’s group benefits plan. After this time, the insurance company revisited her case, asking a doctor to perform an independent medical evaluation. The doctor found no functional impairment so Ms. H.’s benefits were terminated. Ms.

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Submitting claims after you leave a job (health)

Ms. P. stopped working for her employer in April. For the next 90 days (until July), her employee benefits plan would accept any health expenses incurred before her last day of employment. Before she stopped working, Ms. P. saw a health practitioner. He sent a claim submission to the insurance company twice: once in April

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casestudy1

Conversion confusion (life)

Mr. F. had a term life insurance policy through this former employer, which also covered his wife as a dependent. On his 75th birthday, his coverage ended. He confirmed with the insurance company’s call centre that his wife’s coverage would continue because she was not yet 75. Not long thereafter, the company clarified that this

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A mature, African American man in an auto repair shop working on a gasoline engine.  He is wearing a gray shirt and navy blue pants, looking down at the engine with a serious expression.

Sufficient evidence (disability)

Mr. K. was a mechanic with chronic lower back pain. Eventually, he had to stop working. His employer’s group benefits plan covered his long-term disability (LTD) for two years on the basis that he was unable to perform the duties of his “own occupation” during this time. To continue his disability benefits, Mr. K. would

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Handicap patient in a wheelchair at the hospital talking to a friendly nurse and looking very happy - healthcare and medicine concepts

Going the distance (health)

Mrs. O. had lung cancer and lived in a small, remote area. She needed radiation and chemo therapy and chose to go to a city about 400 kilometres away. Her provincial health care plan would reimburse her for travel and lodging expenses if she had to consult a specialist outside her region. Her group health

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Portrait of handsome Asian manager in his office

Information lapse (life)

After Mr. J.’s father died, he claimed the benefits under several term life policies with the same insurance company. All were paid out, except one, which had lapsed several years prior for non payment of premiums. The insurance company denied the claim because they had mailed Mr. J.’s father a Notice of Premium Due before

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Travelers health

Side effects of medications (health)

Ms. E. had extended health insurance through her employer. She disclosed that she suffered from seizures. This insurance also covered out-of-country emergency medical expenses. While on vacation, Ms. E. became ill and was hospitalized. Doctors determined that she had a bad reaction to a drug she was taking to treat a pre-existing condition. While in

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Stethoscope on a printed sheet of paper

Keep dreaming (health)

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

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casestudy1

Going the distance (health)

Mrs. O. had lung cancer and lived in a small, remote area of her province. She needed radiation and chemo therapy and chose to go to a city about 400 kilometres away. Her provincial health care plan reimbursed her for travel and lodging expenses if she had to consult a specialist outside her region. Her

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computer

Hidden history (health)

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

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Disability 2

Precautionary treatments (critical illness)

Ms. K. adopted her daughter and enrolled her in a child development program (CDP), as recommended by the adoption agency. At the CDP, an assessment showed motor problems, including an irregular gait. The next month, Ms. K. applied for critical illness for her daughter. In the telephone interview portion of the application, she said that

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Disability

Steady work (disability)

Ms. H. worked at the front desk of her family’s automotive shop. Her responsibilities were administrative in nature: assisting customers on the phone and in person, processing warranties, selling parts over the counter and traveling around the city to pick up parts. In October, she applied for disability under the company’s group plan, indicating on

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Medical Condition

If the shoe fits… (disability)

Mr. N. was a 54-year-old floor porter, moving packages, equipment and other items around a hospital emergency room. His job required him to be on his feet eight hours a day. His uncontrolled diabetes led to a bone infection in his right big toe and he went on disability benefits through his employer’s group insurance

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Stethoscope on a printed sheet of paper

A limitless drug plan (health)

Mrs. E.’s employer provided everyone in her company with extended health care coverage through a group plan. The plan reimbursed her for 80% of her drug costs, with no limit on cost or any other limits. On her 75th birthday, her company benefits would end. When she was 35, Mrs. E. was diagnosed with a

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Disability 2

Objective medical evidence (disability)

Ms. V. was being treated for major depression and anxiety disorder. Her insurer accepted her disability claim on the basis that she was not able to perform …

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Disability

Fulfilling a policy (critical illness)

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 …

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Life Insurance 2

Honouring a commitment (life)

Thirty years ago, Mrs. B. purchased life insurance. The premium would change over the years and the cash surrender value would be flexible but…

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male doctor holding rx paper in hand

Was he ready to return to work? (disability)

Mr. G. went on a medical leave from work for a year, due to a mood disorder that included depression.

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Medical Condition

Mistaken application (critical illness)

Mr. F. applied for Critical Illness insurance through and submitted his application with the help of his insurance advisor. The insurer rescinded coverage, saying …

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Employee Benefits

Missing policy updates (health)

Mrs. Q. began to see an acupuncturist, paying in advance for a package deal that would reduce the price of each individual treatment. In order to receive …

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Work Desk

Chronic pain and disability (disability)

When Ms. W. went on long-term disability after suffering degenerative disease in her knees, both her individual disability benefit plan provider and the Canada Pension Plan…

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Stethoscope on a printed sheet of paper

Disclosing a change in health (travel)

Mr. S. decided to take advantage of the lower premium rates and purchase travel health insurance several months ahead of a trip to the U.S…

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Disability 2

When’s a medical condition pre-existing? (travel)

Mr. O.’s travel insurance application declared that he was suffering from chronic lower back pain from a fall in 2008. His insurance application was approved, with…

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Employee Benefits

Benefits coordination (disability)

Mr. Y. had been receiving long term disability (LTD) benefits from his insurer for two years. He applied for and was accepted by Canada Pension Plan (CPP)…

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Work Desk

An illness or a symptom? (disability)

Ms. C. had been suffering from chronic migraines and headaches for years, exacerbated by depression and anxiety. She was being actively treated for her conditions…

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What is a “pre-existing” condition? (travel)

Mr. Z. purchased out-of-Canada emergency medical expense insurance in connection with a trip to the U.S. While there, he needed medical treatment for a kidney stone…

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Medical Condition

A key disclosure form (life)

Mr. M. had a $25,000 term life insurance policy. As the premium rates were about to increase dramatically and affordability was an issue, his insurance agent…

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Policy

A critical date (critical illness)

Mr. F., diagnosed with cancer, made a claim on a Critical Illness insurance policy. If his claim was accepted, the insurance would have paid off a $10,000 loan …

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Life Insurance 2

Arriving at a compromise (creditor)

Mr. S. contacted OLHI seeking help with the approval of his disability benefits. The OLHI Dispute Resolution Officer (DRO) who took his call learned that he had purchased a vehicle …

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Family Insurance

Resolving conflicting messages (health)

Mrs. A. called OLHI seeking assistance with her group health benefits. Her insurer had denied payment for treatments recommended for her son’s cerebral palsy and issued her a letter …

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Travelers health

Full disclosure (travel)

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 …

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Policy

A matter of timing (segregated funds)

Mr. and Mrs. D. each purchased a segregated fund investment for a 10 year term. The principal amounts invested were 100% guaranteed if held to maturity.

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Employee Benefits

Jogging some memories (life)

Mr. T. contacted OLHI to seek assistance with reinstatement of his retirement group life insurance benefit. The Dispute Resolution Officer who took the call learned …

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Mortgage

Mortgage relief (creditor)

Mr. S. called OLHI in early 2012. The Dispute Resolution Officer (DRO) who took the call learned that he was currently 61 years of age and had worked as horticulturist …

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Family Insurance

Taking a good hard look at the evidence (disability)

Ms. A. wrote to OLHI seeking assistance after she had unsuccessfully appealed her insurer’s decision to discontinue her disability benefits.

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Travelers health

Coverage uncovered (travel)

An Ontario couple planned a trip to Peru for 20 days, with a departure date of April 18th, 2010. The trip included air fare and a package tour throughout the country.

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Family Insurance

Mistaken meds (life)

Mr. and Mrs. J. purchased life insurance which would pay for their funeral expenses. Two years later, Mrs. J. died of cancer and the family incurred funeral expenses …

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Disability 2

A missing dividend option (life)

In 2003, Mrs. C. purchased two whole life insurance policies – one for each of her children, A. and D. Both policies were purchased at the same time and had face …

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casestudy1

Clearing away the doubts (disability)

Ms. F. called OLHI on behalf of a member of her family, Mr. L., to seek assistance with reinstatement of disability benefits that had been discontinued under his group policy.

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Travelers health

Misadventures in paradise (travel)

Mr. A. contacted OLHI when he was denied reimbursement for a cancelled trip to the Caribbean. By the time he called, his request for payment had been turned down…

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Disability

Two plans, no payments (health)

Mr. R. e-mailed OLHI because he was experiencing difficulty with the administration of his extended health care claims. He had an individual health insurance plan …

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Work Desk

Re-opening the lines of communication (disability)

Ms. M. called OLHI to seek assistance with reinstatement of her disability benefits. Initial discussions with one of our Dispute Resolution Officers revealed that she had received long-term …

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Policy

Who’s on first? (creditor)

When Mr. G. purchased a trailer, he enrolled in the group creditor insurance plan offered by the dealership. His paperwork confirmed he had requested both life and disability insurance …

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Stethoscope on a printed sheet of paper

Was he ready to return to work? (disability)

As a part of his review, the OSO spoke with the consumer as well as the insurer and went through all the documents that both parties shared with him.

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