Ms. P. stopped working for her employer in April. For the next 90 days (until July), her employee benefits plan would accept any health expenses incurred before her last day of employment.
Before she stopped working, Ms. P. saw a health practitioner. He sent a claim submission to the insurance company twice: once in April and, when she didn’t get her claim paid, he sent it again in May at her request.
In August, the insurance company received the expense claim. It was declined because more than three months had passed since Ms. P. stopped working. They suggested that, if dissatisfied, she could seek an independent, free review of her case from OLHI.
Ms. P. explained to OLHI’s Dispute Resolution Officer (DRO) that she had spoken with the insurance company’s call centre in August. She was told that so long as she submitted her paperwork that month, she would get paid. Based on this information, the DRO recommended the case be escalated to an OmbudService Officer (OSO).
Investigating records from Ms. P. and the insurance company, the OSO found some discrepancies: the health practitioner said he sent documents in April and May but there was no evidence that the company received anything until August. The call centre recording revealed that the agent had incorrectly assumed that Ms. P. stopped working in May and that, based on this date, she had until August to submit her claim. Ms. P. did not correct the date, nor did the agent promise she would be paid.
The OSO determined that there was no hard evidence that the health practitioner had submitted a claim to the insurance company before the three months had ended. He also found that the call centre agent had provided the correct advice about the three-month period after an employee stops working – but he just used the wrong timeline, which was not corrected by Ms. P. Details about the claim period were also clearly outlined in the benefits booklet that Ms. P. received when she was hired.
For these reasons, OLHI’s OSO recommended that the insurance company’s decision be 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.