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

An illness or a symptom? (disability)

Work Desk

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. When her loss of concentration began to negatively impact her work product, coupled with her inability to physically sit in front of a computer, she went on short term disability (STD). The insurer denied her claim, citing insufficient clinical medical evidence to support an ongoing condition. The insurer felt that Ms. C. was well enough to work and, upon her appeal, upheld its decision to deny STD.

Ms. C. approached OLHI for an independent, impartial review. The Dispute Resolution Officer (DRO) went through Ms. C.’s records, medical notes from various doctors and specialists, as well as the insurer’s file. He also read a letter from her employer, who verified that Ms. C.’s inability to work and cope with her migraines had negatively impacted the business – and precluded her from performing her regular duties.

The DRO recommended that an OmbudService Officer (OSO) investigate Ms. C.’s case. Upon further review, the OSO focused on a statement the insurer made in its final decision, classifying Ms. C.’s migraines, headaches and depression as “symptoms” lacking a specific medical condition. Ms. C. and her doctors stressed to the insurer and to the OSO that her diagnostic tests (x-rays, CT scans, blood work) were normal/negative to rule out symptoms of a secondary illness, such as tumours – not to rule out her condition.

The OSO agreed that migraines and depression are an illness and not symptoms of another unknown, unsupported condition. Her doctor provided examples from various credible sources, including the World Health Organization, confirming that migraines and depression are illnesses.

OLHI recommended that the insurer reconsider their position and pay Ms. C.’s STD claim.

The insurer, upon further reflection, agreed and provided payment of Ms. C.’s STD benefits.

 

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.