Sample Cases
Category: Benefits
Making Reality Fit the Rules
A frustrated father contacted this Office on behalf of his son, who was a member of the Regular Force when an accident left him permanently disabled. For 12 years following the accident, he lived in an extended-care hospital facility and received the 24-hour care he needed. Sun Life Insurance paid for his room.
Unfortunately, the facility closed and the former member’s family had to move him to another extended-care home. The family was shocked to discover that his room was no longer being paid for, even though his needs had not changed. The social worker at the new facility tried, without success, to get answers from Sun Life Insurance.
When the Ombudsman investigator contacted Sun Life Insurance, he was referred to the Public Service Health Care Plan Trust. The trust administrator explained, after the trust had considered the case, that the provincial Ministry of Health determines which facilities are classified as hospitals and therefore which ones the insurance plan will cover. The new facility did not meet the Province’s criteria. However, the administrator pointed out that there was another facility nearby, and that if the son could be transferred there, his room would be paid for.
Although the answer was not the one the father was hoping for, he was grateful that his son’s care had been carefully reviewed and that he had been provided with the reasons for the decision.
