OLHI ensured that the consumer received a clear explanation and that the procedural concerns were addressed.
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, stating that the medical documentation provided—though it included a diagnosis, functional limitations, a treatment plan, and two consultation notes—was not sufficient to prove the consumer was unable to perform the essential duties of their job.
The insurer also suggested 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, given that the leave was short and that the documentation submitted was consistent with what is typically expected for such a claim.
Due to concerns that relevant medical information may not have been properly considered, the case was 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—details that seemed to have been overlooked.
The insurer agreed to conduct an internal review. After a second round of discussions and further examination, the insurer confirmed that all medical information, including the noted limitations, had been considered. Although the insurer maintained its original decision, OLHI ensured that the consumer received a clear explanation and that the procedural concerns were addressed. The file was closed with the insurer’s final position clarified to the consumer.
The OSO found the insurer’s decision to deny the claim reasonable, but noted that the company could improve its file documentation practices.
