medical records – OLHI – Free, impartial help with your life & health insurance complaints

Dale had a universal life insurance policy.

When his insurance company told him they were going to charge him another premium for the policy, Dale decided to terminate it.

To avoid a Cost of Insurance (COI) charge, the insurer told Dale to send a signed insurance cancellation letter to the same day he terminated his policy.

However, Dale’s insurer didn’t inform him that he needed to include his social insurance number (SIN) in the termination letter. Without the SIN, his policy termination got delayed and Dale was charged the COI. As a result, he received a lower refund than expected.

After he received a final position letter from the insurer, Dale reached out to OLHI to review his complaint.

OLHI’s review confirmed that his insurance company did not tell Dale he had to include his SIN in the letter.

OLHI’s review also found that even after Dale sent in the letter with his SIN, the company asked for it again. OLHI recommended that the insurer reconsider the COI charge for two reasons:

The company did not initially communicate that Dale needed to include his SIN in his termination letter.

When the insurer said Dale needed to include the SIN, he did so, and sent the termination letter within the same day, so the company should have processed it effective as of the receipt date.

Consequently, the insurer agreed and backdated the termination and refunded the COI charge.

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.

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 need to prove that he was unable to perform “any occupation” and unable to earn at least half of his pre-disability salary. The insurance company determined that he did not meet the criteria and denied his LTD claim.

Mr. K. came to OLHI with a final position letter from the insurance company. Our Dispute Resolution Officer (DRO) went through all the supporting documents from Mr. K. and the company. It appeared that the company may have declined the claim prematurely. For this reason, he recommended an OmbudService Officer (OSO) investigate further.

Through his review, the OSO learned that the insurance company based its assessment on medical records that were nearly a year old. Also, its own medical expert stated that more information was needed before making a recommendation on LTD benefits. Specifically, she suggested that the insurance company better understand Mr. K.’s current limitations and look into whether his doctor thought it was possible to work at a sedentary job. Our OSO also wondered why the insurance company had suggested alternate jobs for Mr. K. without fully understanding his current abilities and how much these alternate jobs paid.

OLHI contacted the insurance company and suggested that the decision to deny Mr. K.’s claim appeared to be based on insufficient evidence. He recommended that the insurance company reconsider its position. It agreed to do so and provided Mr. K. with a significant lump sum payment to settle his disability claim.

Tag: medical records

Cancelling an insurance policy – OLHI clears up a mistaken COI charge

Sufficient evidence (disability)