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Submitting claims after you leave a job (health)

Posted on: March 2, 2017

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.

Missing policy updates (health)

Posted on: February 2, 2016

Mrs. Q. began to see an acupuncturist, paying in advance for a package deal that would reduce the price of each individual treatment. In order to receive reimbursement through her group health plan, she had to have a prescription from her family doctor and had to select an acupuncturist certified by a governing board. Mrs. Q. had the prescription but her province did not have a governing board for these practitioners. She selected a certified acupuncturist but, when she submitted her claim, the insurer denied it based on the fact that his credentials were not recognized by them.

As a goodwill gesture, the insurer agreed to cover the costs of the sessions Mrs. Q. went to up to the date of their denial (approximately half of the sessions she’d bought) but would not absorb any costs going forward. She appealed the decision, stating that she had paid for the sessions up front and could not cancel the rest. She also claimed that there was no way for her to know whether or not her acupuncturist’s credentials were recognized by the insurer.

Mrs. Q. contacted OLHI and our Dispute Resolution Officer (DRO) learned that Mrs. Q. had not yet received a final position letter from her insurer. He recommended that she contact the insurer’s Ombudsman and request a final position letter, at which point OLHI could become involved. A couple of weeks following this conversation, Mrs. Q. received this letter and called back the DRO.

The DRO learned that Mrs. Q.’s coverage booklet from her employer did not outline that services would only be covered if the acupuncturist was recognized by certain associations, of which this particular acupuncturist was not a part of. Mrs. Q. could not cancel her future sessions, having paid up front. She asserted that the full package should be covered by the insurer.

With this information, the DRO recommended the case be escalated to the OmbudService Officer (OSO) level to see if there was any room for negotiation with the insurer and to further investigate the reasoning behind their claim denial.

OLHI’s OSO reached out to the insurer’s Ombudsman’s office to further discuss the case, indicating that he felt Mrs. Q. had some valid arguments, based on preliminary findings. It was over the course of the OSO’s exchanges of information that he discovered Mrs. Q.’s employer had received a notice from the insurer the year prior – long before Mrs. Q. arranged for acupuncture treatments. This notice outlined the insurer’s criteria for acceptance of an acupuncturist and a list of recognized associations. Additionally, the notice recommended that employees should submit an estimate to the insurer before going to any expense, so the insurer could review that specific acupuncturist’s credentials.

The insurer acknowledged that it’s possible Mrs. Q. did not see this notice, for any host of reasons – but that it’s the responsibility of employers to ensure such information is properly passed on to employees.

The OSO agreed that the insurer’s decision be maintained, believing it was fair that half the claim had been paid despite the fact that others were responsible for the unfortunate turn of events.