OLHI ensured that the consumer received a clear explanation and that the procedural concerns were addressed.
A denied short-term disability claim
A consumer contacted OLHI after their claim for short-term disability benefits was denied.
The consumer had been placed on medical leave for two months. The insurer rejected the claim.
It stated that the medical documentation provided was not sufficient to prove that the consumer was unable to perform the essential duties of their job. The documentation included a diagnosis, functional limitations, a treatment plan and two consultation notes.
OLHI’s review of the case
The insurer also suggested that the consumer might be able to work in a different context.
OLHI’s Complaints Analyst noted that the insurance company appeared to be mandating an unusually high evidentiary burden. The leave was short, and the documentation submitted was consistent with what is typically expected for such a claim.
There were concerns that relevant medical information may not have been properly considered. The case was therefore escalated to an OmbudService Officer (OSO).
During discussions with the insurer, OLHI raised specific concerns about the lack of commentary on the functional limitations checked by the treating physician in the initial claim form. These details seemed to have been overlooked.
The outcome of OLHI’s involvement
The insurer agreed to conduct an internal review. After a second round of discussions and further examination, the insurer confirmed that all medical information had been considered. This included the noted limitations.
Although the insurer maintained its original decision, OLHI ensured that the consumer received a clear explanation. OLHI also ensured that the procedural concerns were addressed.
The file was closed after the insurer’s final position was clarified to the consumer.
The OSO found the insurer’s decision to deny the claim reasonable. However, the officer noted that the company could improve its file documentation practices.
