Ms. H. worked at the front desk of her family’s automotive shop. Her responsibilities were administrative in nature: assisting customers on the phone and in person, processing warranties, selling parts over the counter and traveling around the city to pick up parts. In October, she applied for disability under the company’s group plan, indicating on the application that she was diagnosed with a respiratory disease.
Three months later, Ms. H.’s family doctor recommended that she be treated with steroids and other medications for respiratory tract infections. She concluded that Ms. H. was not fit for work, except for very sedentary work in a clean environment that would not affect her respiratory disease. Ms. H applied for and was granted disability through the Canadian Pension Plan because her chronic illness and limitations met CPP’s definition of “disabled.”
Ms. H.’s insurance company, through her employee group plan, however, declined her disability claim. They said she had suffered from respiratory problems for many years, before the insurance coverage began. This made her illness pre-existing. The company also said that she was not permanently employed for 24 hours per week and was therefore not insurable.
OLHI became involved when Ms. H. sent us the company’s final position letter and all her documentary evidence. She explained to our Dispute Resolution Officer (DRO) that she was very unwell and unable to work a steady job. The DRO reviewed Ms. H.’s paperwork, as well as files that the insurance company sent. Medical reports confirmed her condition was worsening and made work impossible. With this information, the DRO recommended an OmbudService Officer (OSO) investigate.
The OSO discovered in the insurance policy booklet that an employee’s eligibility for benefits is based on the number of hours worked. A minimum of 24 hours of work was required each week. Ms. H.’s employer could not provide evidence of her hours worked and also admitted that they had paid her when she was ill, even when she did not work. Despite her illness, and despite the insurance company’s empathy, the OSO agreed that Ms. H. could not be covered under the plan.
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.