Mrs. O. had lung cancer and lived in a small, remote area. She needed radiation and chemo therapy and chose to go to a city about 400 kilometres away. Her provincial health care plan would reimburse her for travel and lodging expenses if she had to consult a specialist outside her region. Her group health insurance policy, through her employer, would reimburse her for the rest of what the provincial plan did not cover.
When Mrs. O. submitted her claim, her employer’s insurance company declined it. They said she should have gone instead to a hospital that was closer to her home by 30 kilometres. The insurance policy required that she travel to the closest hospital.
Mrs. O. brought the final position letter to OLHI for a free, independent review of the case. She told our Dispute Resolution Officer (DRO) that traveling to the other hospital would have taken longer in travel time, even if it seemed closer from a distance perspective. She also said she chose the hospital she went to because her specialist was affiliated with it.
OLHI’s DRO reviewed all the information provided by Mrs. O. and by the insurance company. He discovered that the insurance policy carefully outlined reimbursement if a specialist was located more than 200 kilometres away from the person’s home, so long as the specialist was as close as possible to the person. Proximity was based on kilometres, not travel time. The DRO also learned that the provincial plan had declined reimbursement for the same reason.
After thorough review of the policy and discussions with Mrs. O., OLHI explained what the policy said and why Mrs. O. was not able to be reimbursed. The DRO also explained that, for this reason, OLHI believed that the insurance company had made the proper decision.
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.