The consumer reached out to OLHI for help.
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. Based on the initial medical assessment and policy wording, the insurer concluded that the condition did not meet the definition of a covered critical illness, and the claim was denied.
The consumer turned to OLHI for help. Our Complaints Analyst reviewed the case and highlighted concerns about the medical information used by the insurer when rendering its original decision. Given the complexity of the situation, the case was escalated to an OmbudService Officer (OSO) for further review.
Through discussions with the insurer and a reassessment by its medical consultant, it became clear that the medical condition had progressed since the original claim was assessed. With updated information, the tumour was now recognized as aggressive and life-threatening. The insurer reversed its decision and approved the claim.
