Mr. O.’s travel insurance application declared that he was suffering from chronic lower back pain from a fall in 2008. His insurance application was approved, with the pre-existing condition noted. While on holiday, he suffered acute hip pain and, as advised by the insurer, was taken by ambulance to a hospital where he was tested, treated with pain killers and released.
The insurer denied Mr. O.’s claim on the grounds of his pre-existing condition and that he had not reported a steroid injection treatment he received days before his vacation.
Mr. O. appealed the denial, following the insurer’s complaint process. The insurer upheld its’ decision so Mr. O. submitted his complaint to OLHI for review.
Through a review of both the consumer’s and insurer’s documents, the Dispute Resolution Officer (DRO) narrowed the issue down to the insurer’s position that the hip pain was directly related to the steroid injection before his trip. Although the DRO agreed that Mr. O. should have reported the treatment before his trip, she also agreed with his doctor’s view that, given the time between the treatment and the hip pain, there was no direct cause and effect. She suggested that the complaint be escalated to an OmbudService Officer (OSO) for further investigation.
The OSO reviewed the file and also spoke with the consumer. He raised two issues: 1.) Was the hip pain that triggered the hospitalization a pre-existing condition, as defined by the policy; and 2.) Did the injection just before travelling directly contribute to the hip pain? The OSO found that, although Mr. O.’s doctor challenged that the injection caused the hip pain, clinical notes from both the doctor and the hospital’s attending physician supported the insurer’s position that the hip pain was most likely due to the consumer’s chronic lower back pain.
The OSO felt it was unlikely that he could argue that the hip pain was not part of the defined pre-existing condition. He also determined that Mr. O.’s failure to notify the insurer of the injection had deprived the insurer of the opportunity to determine if the injection was a material change to the assumed risk – thereby potentially permitting the insurer to decline coverage.
The insurer’s claim denial was 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.