This case illustrates how OLHI’s process can lead to meaningful outcomes.
The denied medical expense claim
A consumer contacted OLHI after a reimbursement claim was denied. The claim involved nearly $10,000 in medical expenses under their mother’s visitor travel insurance policy.
The consumer’s mother had travelled to Canada under a Super Visa, which allows parents and grandparents to stay in Canada for an extended period. During her stay, she experienced a medical emergency and was taken to the emergency room. She was then hospitalized.
She underwent several procedures, including endoscopic retrograde cholangiopancreatography, also known as ERCP. This procedure is used to diagnose blockages in the bile or pancreatic ducts. It can also be used to treat them.
The insurer denied a significant portion of the claim. It argued that the ERCP was investigative and not urgent. According to the insurer, the procedure could have been postponed until the insured returned to her home country.
The consumer strongly disagreed with the decision. They believed the procedure was part of a continuum of emergency care.
OLHI’s review of the case
OLHI’s Complaints Analyst reviewed the case and identified several issues. The ERCP had resulted in the removal of sludge and stones. This suggested that the procedure was not merely investigative, but medically necessary.
The Analyst also noted that the insurer had not consulted a specialist. The insurer had not properly applied the policy’s definitions of “emergency,” “medical emergency” and “medically necessary.”
There was also no evidence that the emergency had ended. It appeared to be ongoing when the insured was transferred for the procedure.
The resolution of the complaint
Informal negotiations were held with the insurer, and further clarification was provided. Following these discussions, the insurer agreed to make a partial payment.
The payment represented approximately half of the amount that had initially been denied. It was made on an extra-contractual basis in exchange for a release.
The consumer accepted the proposed settlement, and the complaint was resolved. This case shows how OLHI’s process can lead to meaningful outcomes. It can challenge decisions while ensuring that evolving medical knowledge is considered when it matters.
