group disability – OLHI – Free, impartial help with your life & health insurance complaints

Conflicting medical reports (disability)

Posted on: June 26, 2017

Ms. C. worked as an office administrator, a predominantly sedentary role. She began to experience medical conditions that affected her back. Her employer’s group disability insurance plan covered her short-term disability claim. After several months, the insurance company denied Ms. C.’s coverage for long-term disability (LTD), stating that her illness did not prevent her from performing her job. The final position letter explained that Ms. C’s illness lacked clinical medical information to satisfy the terms of the disability contract.

After receiving this letter, which pointed to OLHI as an independent dispute resolution service, Ms. C. approached OLHI. In her review, OLHI’s Dispute Resolution Officer (DRO) noted that medical reports determined Ms. C. was not fit for work and that her condition was deteriorating. Meanwhile, the insurance company interpreted the reports differently, finding there was an improvement in her condition. The DRO also questioned whether the insurance company was relying too much on looking for neurological evidence that did not directly correlate with Ms. C.’s diagnosis from her doctor and specialist.

With these questions in mind, the DRO recommended an OmbudService Officer (OSO) further investigate Ms. C.’s complaint.

OLHI’s OSO learned that the tests conducted on Ms. C. returned with negative or mild/moderate results. Medical reports recommended that she could still perform sedentary or light duties, fitting with her job description, and her doctor supported a gradual return to work program. However, Ms. C.’s employer declined the program and instead ordered an independent medical examination, which concluded that she was not fit to work. Meanwhile, other conflicting medical reports suggested that Ms. C.’s condition was deteriorating because of an unhealthy lifestyle and not because of her diagnosis affecting her back.

Given the conflicting information and the employer’s refusal to have Ms. C. return to work because of its own medical findings, the OSO recommended that the insurance company and the employer reach an agreement. With OLHI’s recommendation, Ms. C. was able to reach a settlement.

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.

Taking a good hard look at the evidence (disability)

Posted on: February 2, 2016

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.

Clearing away the doubts (disability)

Posted on: February 2, 2016

Ms. F. called OLHI on behalf of a member of her family, Mr. L., to seek assistance with reinstatement of disability benefits that had been discontinued under his group policy. Mr. L. could not act for himself due to his state of disability. The OLHI Dispute Resolution Officer (DRO) learned that short-term disability benefits had been paid for a period of six months. Long term disability benefits were paid, on a trial basis, for a year and were then discontinued following an independent medical examination conducted on behalf of the insurer.

In sum, based on the medical examination, the insurer suspected that the insured was feigning his disability. The insurer also queried whether Mr. L. met the condition of “total disability” as per his insurance contract. Ms. F. called OLHI seeking assistance with the reinstatement of benefits. The complaint was initially reviewed by a DRO and was then referred to an OmbudService Officer (OSO) for a more detailed examination.

As is usual, Mr. L.’s group disability plan provided benefits for a period of 24 months if a claimant can demonstrate disability from his or her own pre-disability occupation. In order to qualify for benefits after that period, the claimant must provide evidence to support his or her inability to perform any occupation for which he is reasonably suited by education, training or experience.

OLHI’s OSO reviewed the extracted documents from the claims file previously provided to Ms. F. by the insurer. He then spoke at length with her to ascertain the chronology of events and the extent of her involvement to date. Taking into account the information already available, he determined that this case would best be served by a review of the insurer’s claim file. The insurer readily agreed and cooperatively provided the complete claim file.

A review of the insurer’s claim file and the additional information provided by the insured’s representative disclosed that Mr. L. had subsequently left his minimum wage-type work in the hospitality industry in order to be closer to his family. The file also revealed a history of progressively worsening mental health, culminating in Mr. L.’s hospitalization by the time of the OSO’s review.

The OSO appreciated the reasons for the insurer’s concerns about proof of disability, which were based on anecdotal evidence that suggested Mr. L. was physically active and had made some efforts to find a job. However, our Officer’s review of the claim history led him to conclude that the insured was indeed suffering from a serious deteriorating mental disability. This disability had not been clearly diagnosed at the time of the insurer’s decision to terminate benefits but had been conclusively diagnosed by the time OLHI’s Officer was reviewing the case.

Upon conclusion of his review, the OSO made a detailed written submission to the insurer. He acknowledged the insurer’s concerns and the fact that this was a challenging and complex claim. However, his view was that the evidence did not support a conclusion of feigning on the part of the insured. He suggested that the totality of the subsequent circumstances, which indicated a progressive deterioration in mental health, also be taken into account.

Upon receipt of our Officer’s analysis, the insurer referred the case back to its business unit for further consideration. In due course, the insurance company offered Mr. L. a lump sum settlement or reinstatement of the claim back to a point in time where the insurer accepted that Mr. L. was unquestionably totally disabled from any occupation. This offer was considered fair by OLHI’s OSO and the reinstatement of claim option was eventually accepted.