Mr. S. decided to take advantage of the lower premium rates and purchase travel health insurance several months ahead of a trip to the U.S. While in the U.S., he went to a clinic and was diagnosed with bronchitis and then went back to the clinic because of side-effects from the medications prescribed for the bronchitis.
Mr. S.’s insurer rejected his claim because his application did not disclose his gastro-intestinal problems and because he did not notify the insurer of treatment he had received since buying the insurance. After getting his travel insurance coverage, but before going on the trip, Mr. S. had a colonoscopy and removal of a polyp. The insurer denied the claim and subsequent appeals due to material non-disclosure.
After Mr. S. received the insurer’s final position letter, he called OLHI and submitted his complaint for our review.
A Dispute Resolution Officer (DRO) found that call recordings at the time of purchase supported that Mr. S. had disclosed his medical information, including past findings of diverticulitis. As explained by Mr. S., he had not checked the box on the policy application asking if he had been treated or taken medication for any gastro-intestinal condition, as he was not taking any medication for diverticulitis. Neither he nor his doctor felt that regular colonoscopies should be deemed “treatment.”
The policy said that the duty to disclose pre-existing conditions at the time of the application was based on the definition of “treatment,” whereas after policy issue, the eligibility for coverage was based on a change in health condition or medication.
OLHI advised the insurer that Mr. S.’s complaint had merit and would therefore be escalated to our investigation level. Before this investigation was started, the insurer advised that, upon further consideration, they would fully reimburse Mr. S. for his expenses.
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.