Mr. G. went on a medical leave from work for a year, due to a mood disorder that included depression. During this time, through his group insurance plan, his employer covered his disability benefits. But after a year, the insurer terminated benefits upon receiving information from Mr. G.’s doctor that he was planning on returning to work. He did not, though, as his psychiatrist stated that he was unable to. The insurer completed a medical investigation and, in its final position letter, wrote that Mr. G. was not completely disabled and could return to work.
Mr. G. contacted a Dispute Resolution Officer (DRO) at OLHI. The DRO discovered that while Mr. G’s doctor had recommended he return to work, his psychiatrist did not support the finding and felt that Mr. G. was still suffering from a severe disorder. For this reason, the DRO recommended the complaint be escalated to an OmbudService Officer (OSO) for investigation.
As a part of his review, the OSO spoke with the consumer as well as the insurer and went through all the documents that both parties shared with him. The medical reports revealed that even after his disability payments stopped, his psychiatrist continued to treat Mr. G. for his illness. The OSO also discovered a crucial detail: that the insurer’s decision to stop disability payments was based on a conversation with Mr. G.’s psychiatrist, where he said Mr. G. had quit his job. However, the transcript of this telephone conversation did not match formal reports. Mr. G. explained to the OSO that his psychiatrist may have confused the fact that he quit another job many years earlier.
The OSO reached out to the insurer, requesting they confirm with the employer whether Mr. G. had in fact quit or was still employed and on leave. The employer was able to confirm that he had not quit his job. After some further discussion, the insurer agreed to reconsider and made a settlement offer. Mr. G. was thrilled to reach a settlement and was also very appreciative of the way the OSO was able to explain his case in plain language to him so that he could better understand how the insurer reached their initial decision.
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.