Lost in the mail

A 62-year-old woman with Crohn’s disease required infusions every eight weeks at a cost of $4,542.76 per treatment. The woman’s private insurance covered 80% of the costs, while the Trillium Drug Program reimbursed her for the remainder, but she was reaching the lifetime maximum for her private insurance coverage and it was about to end.

The woman contacted the Trillium Drug Program to make sure it had the information it needed to cover the full cost of her infusions in future. A Trillium agent asked the woman to provide a letter from the private insurer confirming the coverage was ending. The woman submitted the letter, then contacted Trillium again to confirm her account had been adjusted. A different agent told the woman she would need to submit a second letter confirming the date the private coverage would end. The woman did so, but was contacted by yet another Trillium staff member who asked her for a third letter confirming her benefits would not be reinstated in the future. She asked to speak to a supervisor, but didn’t receive a return call.

After dealing with the issue for more than a month, the woman contacted the Ombudsman, frustrated and concerned that due to Trillium’s convoluted system, her Trillium account wouldn’t be adjusted to cover the costs of her next treatment, which was only three weeks away.

Ombudsman staff escalated the woman’s concerns to senior Trillium staff at the Ministry of Health and Long-Term Care, who acknowledged the woman had received poor customer service and had been asked for unnecessary information. Trillium provides information to its call centre employees about what is required from a private insurer upon the termination of private coverage, but to prevent this situation in the future, the Ministry agreed that Trillium staff would be required to contact clients in writing to confirm what’s needed if the initial information the client provides isn’t adequate. The Ministry also agreed to update its website with more information about private insurance matters.

The Ministry expedited the review of the woman’s application, and within three days of her call to the Ombudsman, her application was approved and her coverage was updated.

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