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Resolving conflicting messages (health)

Family Insurance

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 referring her to OLHI if she wished to further pursue her complaint. All Canadian life and health insurers who are members of OLHI issue such a letter, known as a “final position letter,” once their internal company complaint process is completed.

Based on their conversation, the Dispute Resolution Officer (DRO) concluded that OLHI could proceed with an independent review of Mrs. A.’s complaint once she had signed and submitted OLHI’s Authorization form. A letter was then sent to Mrs. A. confirming that the complaint had been opened and she could expect to hear from OLHI within 60 to 90 days. Copies of all documents relevant to the complaint were requested from both Mrs. A. and her insurer, including her employee benefits brochure and all relevant correspondence.

The documents submitted by both parties were reviewed by the DRO. He noted that the definition of “eligible expense” in the insurance policy and in the benefits brochure contained several conditions. Nevertheless, he was not convinced that the terms of the insurer’s policy clearly explained why and how the claim was not eligible. He noted that conflicting messages may have been given by the insurer. Accordingly, he recommended that the complaint be escalated to an OLHI OmbudService Officer (OSO) for further review.

Upon receipt of the complaint file, the OSO reviewed the proceedings to date, including the documents from both parties. He then spoke at length with Mrs. A., who had been left confused by the insurer’s communications.

He learned that initially, Mrs. A. was told the treatments would be covered. She was then advised, in writing, that the proposed treatments were not eligible because they were not considered “reasonable,” although the insurer offered to reconsider its’ position if she could demonstrate that the treatments were medically supported. Based on this information, Mrs. A. obtained a letter from her son’s doctor justifying the treatments but the insurer denied the claim once again.

In the meantime, a representative of the insurer had mentioned to Mrs. A. that treatments of this nature had been previously allowed on an individual basis.

The OSO contacted the insurer to gain a better understanding of its’ position. In particular, he wanted to understand why Mrs. A.’s claim had been turned down after she had submitted medical evidence that, on its face, seemed to prove that the treatments were medically reasonable. He was told that the proposed treatments were not eligible for payment because the relevant section of the policy was intended only to cover the cost of medical equipment, not the treatments themselves.

A further review of the insurer’s claim file by the OSO disclosed that the position that only medical equipment was covered had surfaced after the insurer had advised Mrs. A. in writing that “medically reasonable” treatments would be paid.

The OSO then made a detailed submission to the insurer. He recommended that, in light of the lack of clarity in the policy wording and the insurer’s conflicting and confusing messages to the consumer, it might consider allowing the claim without recourse to the experience-rating of the policy.

The insurer agreed to do so, and the course of treatments was allowed.

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.