Mrs. R. frequently traveled out of country. She purchased a travel health insurance plan that would cover her for 35 days every time she left Canada. She departed in February and in May, while still on her holiday, she suffered a major illness, was hospitalized and passed away two weeks later.
While Mrs. R. was in hospital, her son, Mr. R., became involved. When he and the doctors reached out to the insurance company, the company confirmed that it would be able to help. Mrs. R. was transferred from one hospital to another for specialized care – a transfer that the company helped coordinate.
The insurance company denied the claim because the policy’s coverage had expired. In its final position letter, the company told Mr. R. about how OLHI reviews matters that consumers have not been able to resolve with their company. He contacted OLHI and asked a Dispute Resolution Officer (DRO) to become involved.
Mr. R. told the DRO that the company confirmed several times that his mother would be covered by the policy. He had no idea that her coverage was for only 35 days because he did not find this out from the company until after incurring costs.
Because of the complexity of the complaint, the DRO recommended that an OmbudService Officer (OSO) become involved to further delve into the investigation and to determine whether there were grounds for conciliation.
The OSO reviewed documents provided by all parties. He also listened to the recordings of telephone calls between Mr. R. and the company, as well as between the hospital and the company. In these calls, the company said that it would help with the hospital transfer but that it was not a guarantee of coverage because the claim still had to be processed and reviewed for approval. In those conversations, the company did not yet know when Mrs. R. had left on her out-of-country trip.
The OSO recommended that there were no grounds to pursue. The company’s claims process included confirming the coverage period. He also agreed that while the company said that Mrs. R. had insurance coverage, it also said that her claim still had to be reviewed to confirm she met the policy’s terms of coverage.
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.