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Taking a good hard look at the evidence (disability)

Family Insurance

Ms. A. wrote to OLHI seeking assistance after she had unsuccessfully appealed her insurer’s decision to discontinue her disability benefits. Her group disability plan provided payments for a period of 24 months upon inability to perform her own occupation. In order to qualify for benefits after that period, she was required to provide evidence of inability to perform any occupation for which she was reasonably suited by education, training or experience.

This matter was directed to an OLHI Dispute Resolution Officer (DRO) experienced in disability claims. He followed up with Ms. A. and learned that she was a physiotherapy assistant, a highly physical job. Several years before, she had sustained a leg fracture requiring surgery. She had submitted a claim for disability payments under her group disability program and was granted benefits. He also learned that Ms. A. had cooperated with the insurer’s efforts to get her back to work by actively participating in a prescribed rehabilitation plan and by undergoing a functional capacities evaluation (FCE) to determine her capacity to work. Following the FCE, Ms. A. received a letter from her insurer advising that her benefits would terminate in six months’ time, upon conclusion of the “own occupation” period. Ms. A. appealed her insurer’s decision to terminate benefits on several occasions without success.

Following their conversation, our DRO reviewed the documentation that he had requested from her. This included correspondence with her insurer, medical reports, the FCE, and materials she had submitted to CPP in support of a claim for disability benefits. He noted that although the insurer had concluded from the FCE that Ms. A. could do “sedentary work”, the report itself indicated only “perceived ability at sedentary, tolerated light capacities.” No Transferable Skills Analysis (TSA) had been undertaken by the insurer to support a conclusion that Ms. A. had the skills and capacity to transition to a sedentary occupation, such as secretarial or receptionist duties.

He also observed that the insurer, in making its decision to end benefits, appeared to give significant weight to the fact that during the initial benefit period, Ms. A. had excelled in a six week training course in medical terminology and had also responded to job advertisements in which she might apply these skills. In addition, it was noted that there was clear and credible evidence of deterioration in her medical condition in the two years following the termination of her benefits.

All of these factors were instrumental in our DRO concluding that there were grounds to refer this complaint to an OLHI OmbudService Officer (OSO) for a more thorough review.

The OSO reviewed the file, spoke at length with Ms. A., and determined that the next step should be a review of the insurer’s claim file. In accordance with OLHI’s procedures, the insurer readily produced this file upon request.

Upon reviewing the insurer’s file, it appeared that the denial of Ms. A.’s disability claim was based on an apparently successful vocational rehabilitation program and the FCE performed 18 months into her 24-month initial claim period.

On the other hand, the insured’s physical and mental condition had been deteriorating and she had clearly struggled to complete her rehabilitation program to prevent loss of her benefits. Also noted were conflicting views in the insurer’s own file as to the likelihood of her ability to function in any kind of work setting. Moreover, while Ms. A.’s original application for CPP disability benefits had been initially denied, her claim was subsequently approved.

Upon conclusion of his review, the OSO made a detailed written submission to the insurer with a recommendation that the insurer review its decision.

In due course, the insurer responded with an offer to have Ms. A. submit to an independent medical examination. This examination determined that she was, indeed, unable to function in any occupation for which she might be reasonably suited by education, training, or experience.

The insurer accepted the independent medical examiner’s assessment and promptly agreed to allow benefits on a continuing basis, subject to an appropriate adjustment with respect to the CPP benefits already received.

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.