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Revisiting an old claim (disability)

Medical Condition

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. H. brought the insurance company’s final position letter to OLHI, asking a Dispute Resolution Officer (DRO) to review her case. The DRO asked her and the company for all their relevant documents. In his review, he read that the insurance company had conducted a transferable skills analysis several years earlier and they found she could not perform any jobs identified. In their file, they noted that they expected to make payments until Ms. H. turned 65 – but she was several years younger when the LTD benefits stopped.

The DRO recommended an OmbudService Officer (OSO) further investigate.

The OSO learned from the insurance company that it was their practice to review its cases over time. If necessary, they revised their findings based on new information, regardless of original predictions. In Ms. H.’s case, the insurance company followed up with her because she had been on a waiting list for surgery for many years. It turned out that the surgeon had lost her contact information and she was no longer on a waiting list. Ms. H. had never followed up with this surgeon since seeing him several years earlier, so she did not know that she was no longer on a list.

The insurance company requested a new evaluation by an independent doctor, who did not find any medical evidence supporting severe disability. She recommended that Ms. H. could work at a job that matched her abilities, experience and education – but required less physical activity.

OLHI’s OSO carefully reviewed all these facts from Ms. H. and from the insurance company. It was his recommendation that the insurance company’s decision be maintained.

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.