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

If the shoe fits… (disability)

Medical Condition

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 plan. The insurance policy provided disability payments for the first 24 months so long as Mr. N. was not able to perform the essential duties of his job.

For the first six months, the insurance company paid Mr. N.’s disability benefits. Then, the company stopped, explaining that his infection was resolved and his condition did not prevent him from returning to work.

Mr. N. brought the company’s final position letter to OLHI. He told our Dispute Resolution Officer (DRO) that he could not return to his job because it required that he wear safety shoes. The bone infection had caused a deformity and limited sensation in his leg. The constant friction caused pain when he wore safety shoes. Additionally, he had dizziness from his diabetes.

Our DRO carefully reviewed all Mr. N.’s files, as well as the files sent by the insurance company. She learned that Mr. N.’s medical records confirmed that it was unlikely he could return to work in steel-toed boots. He was unable to properly stand on his feet, his walking was slow and his reflexes impaired. Mr. N.’s employer also confirmed that safety shoes were mandatory for the job.

The DRO recommended an OmbudService Officer (OSO) conduct a further review based on merit, given the physical nature of Mr. N.’s work. The OSO contacted the insurance company after his own through review, recommending that the medical evidence was quite definitive and prevented Mr. N. from performing the duties of his job. The insurance company agreed and continued to pay for his disability benefits for the rest of the 24 months.

 

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.