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

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.

Mr. K. was a mechanic with chronic lower back pain. Eventually, he had to stop working. His employer’s group benefits plan covered his long-term disability (LTD) for two years on the basis that he was unable to perform the duties of his “own occupation” during this time.

To continue his disability benefits, Mr. K. would need to prove that he was unable to perform “any occupation” and unable to earn at least half of his pre-disability salary. The insurance company determined that he did not meet the criteria and denied his LTD claim.

Mr. K. came to OLHI with a final position letter from the insurance company. Our Dispute Resolution Officer (DRO) went through all the supporting documents from Mr. K. and the company. It appeared that the company may have declined the claim prematurely. For this reason, he recommended an OmbudService Officer (OSO) investigate further.

Through his review, the OSO learned that the insurance company based its assessment on medical records that were nearly a year old. Also, its own medical expert stated that more information was needed before making a recommendation on LTD benefits. Specifically, she suggested that the insurance company better understand Mr. K.’s current limitations and look into whether his doctor thought it was possible to work at a sedentary job. Our OSO also wondered why the insurance company had suggested alternate jobs for Mr. K. without fully understanding his current abilities and how much these alternate jobs paid.

OLHI contacted the insurance company and suggested that the decision to deny Mr. K.’s claim appeared to be based on insufficient evidence. He recommended that the insurance company reconsider its position. It agreed to do so and provided Mr. K. with a significant lump sum payment to settle his disability claim.

Tag: ltd

Sufficient evidence (disability)