The consumer reached out to OLHI for help.
A denied critical illness claim
A consumer had undergone surgery for a brain tumour and believed they were entitled to coverage under their policy.
However, the insurer concluded that the tumour, initially classified as benign, did not meet the policy’s definition of a life-threatening cancer. The decision was based on the initial medical assessment and policy wording. The insurer therefore concluded that the condition did not meet the definition of a covered critical illness and denied the claim.
OLHI’s review of the case
The consumer turned to OLHI for help. Our Complaints Analyst reviewed the case and raised concerns about the medical information used by the insurer in its original decision. Given the complexity of the situation, the case was escalated to an OmbudService Officer (OSO) for further review.
Medical reassessment and claim approval
Following discussions with the insurer, its medical consultant reassessed the case. It became clear that the medical condition had progressed since the original claim was reviewed.
With updated information, the tumour was now recognized as aggressive and life-threatening. The insurer reversed its decision and approved the claim.
