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OLHI OLHI – Free, impartial help with your life & health insurance complaints

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Decoding Life and Health Insurance Policies: A Simple Guide

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Life and health insurance policies can be confusing. Unless you work in the sector, all the industry-specific language, details, and different clauses and subclauses might sound like a foreign language. 

But don’t worry! You’re not alone in this. This guide will help you make sense of your insurance policy. 

Ready to get started? Let’s learn how to read a life or health insurance policy together. 

Key Takeaways

→ Knowing how to read an insurance policy  

→ Common elements in policies that consumers often overlook 

→ What to do if you have a complaint about your life or health insurance 

What’s in your policy?

Policy benefits

Your journey begins with the benefit details of your coverage. This section’s title varies from company to company. Typically, it is titled Benefits Schedule, Policy Specifications, Policy Details, or a similar term. A Policy Benefits section summarizes your policy. It includes details like your policy number, coverage amounts, policy duration, and premium amounts. 

Definitions

Every policy includes a definitions section. Understanding these terms is critical to make sense of your policy. For example, ‘beneficiary’ in a life insurance policy refers to the individual receiving the payout upon the life insured’s death. Read the Definitions section carefully. If you find terms you don’t understand, consult this comprehensive glossary of insurance terms or contact your insurer for an explanation. 

Coverage

The Coverage section explains what your policy covers and for how much. Health insurance coverage might include hospitalization, medication, and surgical procedures. Life insurance coverage usually includes the death benefit and may also encompass situations like terminal illness. Disability insurance coverage usually makes monthly payments to replace income if you become disabled and are unable to work. 

Exclusions

Exclusions clarify what a policy won’t cover. A close read of this section will prevent unfortunate surprises later. Never assume you have coverage for a particular situation or service – read the Exclusions to know what not to expect.

Limitations/Restrictions

Limitations are conditions or procedures covered under a policy but at a benefit level lower than the norm. Restrictions are conditions or procedures covered but with some conditions. 

Premiums

Premiums are the amount you’ll pay to keep the policy active. Knowing how much you must pay every month and what day payment is due is crucial. For example, if you default on a life insurance payment, you lose your coverage if you don’t make the payment within the grace period. 

Beneficiaries

For some types of policies, like life, annuities, critical illness or disability policies, you’ll need to designate who will receive the benefits in the event of your death. The beneficiary is often, but not always, a spouse or partner. Make sure this information is correct and update it when your circumstances change. 

Claims

Lastly, your policy will explain how to file claims. Familiarizing yourself with this process can prevent complications during a challenging time. 

Four Things Often Overlooked in Insurance Policies

The sheer volume of information can be overwhelming when reading an insurance policy. Here are four common things consumers often overlook when reading a policy: 

Policy Exclusions and Limitations/Restrictions

When you buy an insurance policy, it’s easy to focus on what is covered and miss important information about the exclusions, limitations or restrictions. For example, some health insurance policies might exclude pre-existing conditions.

Waiting Periods

Insurance policies often have waiting periods during which you are not covered/paid even though you’ve started paying premiums. Waiting periods are especially common in disability insurance. It’s essential to know how long this period is to better plan your disability period. 

Definitions

Consumers sometimes make incorrect assumptions about what the terms mean in their policies. Review the Definitions sections before you incur any expense you think should be reimbursed by your insurer. Besides the main Definitions section we discussed above, there may also be specific definitions within the policy’s descriptions of each type of coverage.

Updating your address

As the policy owner, you must inform the insurance company of any change to your mailing address. It is also helpful to provide the insurer with your email address as so much of modern business communications are performed by email rather than by Canada Post. Not updating basic personal information like your address can have severe consequences on the outcome of a claim or when it is time for renewal of the policy and there is a change in the premium amount. 

What to do if you have a life or health insurance complaint?

Disputes between consumers and insurers do happen. If you disagree with your insurance company’s decision about your claim, you can ask them to take another look. Every insurer in Canada is required to provide consumers with a process to deal with complaints. 

And if you are still not happy at the end of your insurer’s complaints process, OLHI is here to help. You can submit your complaint to OLHI for a free, fast, independent and impartial review. Learn how the process works here. 

Case Study

Resolving Conflicting Messages – OLHI helps mother and child with a refused health insurance claim

Read the case study

Conclusion

A close, informed reading of your life or health insurance policy can make all the difference when you need it most. Knowing what the terms mean and what is included in your policy (and what’s not) helps you make informed decisions.

For more information, consult the Canadian Life and Health Insurance Association’s Consumer Information and Guide to Life Insurance.

A Guide to Travel Insurance

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This Guide to Travel Insurance will help you understand what coverage you need and have peace of mind while travelling abroad.

On this page:

→ Types of travel insurance

→ How to choose which travel insurance to buy

→ How to ensure you have adequate coverage

→ Trip cancellations

→ Travel insurance exclusions to ask about

→ Just before you travel…

→ Top 5 reasons for denied travel insurance claims

Download our Travel Insurance Checklist

Types of travel insurance

At a high-level, there are four key types of travel insurance to choose from:

Per Trip

This type of travel insurance applies to a single trip—like a family vacation to Florida or a romantic trip with your loved one to Paris.

Annual

This type of insurance is better suited for travellers who spend extended amounts of time outside of Canada—for example, snowbirds travelling to Florida for several months.

Bank card

Credit cards can also offer travel insurance coverage for medical emergencies or trip cancellations and material losses like lost baggage or auto accidents.

Group benefits

Your extended health care benefits (AKA group benefits) may grant you access to reduced travel insurance premiums.

A family getting ready to go on a road trip.

How to choose which travel insurance to buy

When selecting the correct type of travel insurance, get qualified advice from a professional on what kind of coverage to buy. Our Find Insurance tool can help you find which of our member companies offer travel insurance.

Don’t be shy—ask your insurance provider as many questions as you need to feel comfortable and confident about your policy. Download our Travel Insurance Checklist Download our Travel Insurance Checklist to make sure you ask all the important questions when selecting an insurance policy that meets your needs.

TIP: Don’t wait until the last minute to figure out your travel insurance plan.

It’s natural to be excited about your trip and focused on planning all the fun details. Still, it’s crucial to spend time and part of your budget to plan which travel insurance to buy. Last-minute decision-making about travel insurance often leads to selecting a cheaper plan, which can cause problems in the long run.

How to ensure you have adequate coverage

Making sure you have enough coverage for emergency medical care expenses is essential for selecting travel insurance.

Your base coverage should include emergency medical care expenses for you and your family (if they are travelling with you.) The amount of coverage you need will depend on your situation. You can expect a coverage range from $3M to $5M CAD. Clarify the deductible—if it’s 100%, it may cost more now, but it could save you a lot of money in an emergency.

Also, find out the limit or aggregate maximum payable for everyone covered by your insurance policy. The maximum payable amount is vital if an emergency (like a natural disaster, a pandemic, or a military conflict) occurs during your trip. If your policy has a maximum payable amount, it could reduce the total amount of medical coverage you are entitled to.

TIP: Get your insurer’s emergency contact number.

Ask your insurance provider if they provide a worldwide 24/7 emergency contact number in English and translation services for health care providers in your destination country.

There are four key things your travel insurance should always cover:

Medical evacuation

Your policy needs to cover the cost of your medical evacuation to Canada (or the closest location you can get adequate medical care.) These costs should include a medical escort accompanying you during your evacuation.

Pre-existing medical conditions

Many policies will have a pre-existing condition clause. This means that if you suffer from a pre-existing condition, any claim related to it will be excluded from the coverage of your policy.

Ask for the insurer’s specific definition of “pre-existing medical condition” and any limitations this definition may impose on you based on your medical history. Don’t forget to ask about coverage for mental health conditions or pregnancy if either of these conditions apply to you.

Ask for a written agreement from your insurance company that says it will cover your pre-existing medical condition(s). Ensure the written agreement includes these clauses:

  • A stability clause will state the duration of coverage for pre-existing medical conditions before your trip—also known as a stability period. Your medical condition cannot change during this period (including medications and symptoms.) In other words, this clause confirms coverage for a pre-existing condition because it has remained stable over a defined duration.
  • A compassion clause, which states that an inaccurate statement from you may not invalidate your entire policy. 
  • A change of health clause covers you if your medical condition changes before your trip.

Repatriation in the event of death

Ask your insurance company if the travel insurance policy in question covers repatriation. It’s certainly not something anyone wants to consider before a vacation, but if you pass away while abroad, repatriating your remains back to Canada can be difficult and expensive.

Having a plan in place, just in case, will mean lifting a substantial financial burden off the shoulders of your family.

Your travel timeframe

Be very clear about when you’ll be travelling and if outside of Canada. Ask if there is a maximum timeframe for coverage. Find out if you can renew or extend your insurance coverage and, if so, how much notice your insurer needs to extend it.

If you decide to extend your trip but are injured and need medical care, you will not be covered if your policy has expired.

A family upset about a cancelled trip.

Trip cancellations

Cancellation rules depend on your insurer and your policy. You’ll need to ask questions about the conditions that allow trip cancellation, clarify if your insurer will reimburse you, and how much.

Ask the insurance company about when the policy’s effective date occurs (in other words, the date when your policy begins), which can vary depending on the type of insurance purchased. Insurers may allow you to cancel your travel insurance with a full refund before the effective date of your policy, but never assume this will be the case for you. Always ask direct questions and confirm when the effective date will occur.

You should also ask about extenuating circumstances beyond your control that could cancel a trip, like a natural disaster or military conflict. Find out which external risks are covered under your policy and what would happen in the event of such a disaster—namely, would you be refunded.

It is especially important to verify whether the insurance company will deny a claim if the travel agency, airline or other provider of travel services (including hotels) offers you a credit or voucher. Sometimes, a credit or voucher will be of no use, such as for a student whose trip to Europe in their last year of high school got cancelled.

Case Study:
Misadventures in Paradise

Find out how OLHI helped a consumer when he was denied reimbursement for a cancelled trip to the Caribbean:

Read the case study

Travel insurance exclusions to ask about

In Canada, we’re fortunate to have access to universal health care. For example, suppose Susan becomes sick with pneumonia within her hometown of Halifax and needs emergency hospital care. In that case, our Canadian universal insurance plan will cover her treatment costs.

But, if Susan becomes sick while visiting family in the United States and needs emergency treatment, she could face hefty hospital bills without adequate insurance because of certain exclusions. This is one more reason you must be careful when you purchase your insurance.

Indeed, say Susan obtained travel insurance before her trip to the US. Yet, she forgot to include details about a pre-existing condition in her insurance application. This omission could jeopardize her insurance claims for hospital care in the US and devastate her financially because her policy could be null and void. The Government of Canada will not cover these bills.

Case Study: When’s a medical condition pre-existing?

Learn how OLHI helped a consumer when he was denied reimbursement due to a pre-existing condition:

Read the case study

Here are four key exclusions to ask about and factor into your travel insurance purchase:

Medical

It is crucial that you disclose your full medical history in your application to your insurance provider. Don’t leave anything out.

The primary reason insurers deny travel insurance claims is the insurer’s discovery of a pre-existing condition when there is indeed a pre-existing exclusion in the policy. Also, if an insurer discovers missing medical detail from your application which can be considered as misrepresentation or concealment. The insurer can determine that this information was “material to the risk.”

In other words, if the insurer had known about this piece of information, they either wouldn’t have issued the policy or would have charged a higher premium. Also, the missing details don’t need to be related to the claim for the insurer to cancel the policy.

Are you wondering how your insurer can tell if you left out medical history details from your application? They will require and review your clinical notes to process your claim.

Also, if your medical condition changes before your trip—due to something as minor as a nosebleed or a cough—call your insurance provider and let them know about it.

TIP: Ask your physician to complete the health questions in your application.

Ask your physician to complete the health questions in your application. They may charge a fee, but it could be one of the best investments you’ll ever make—a claim in a US hospital could be for $200,000 CAD or more.

Who you are travelling with

Ask specific questions about who in your travel party falls under your coverage plan. Suppose you’re travelling with your significant other, but you don’t live together. In that case, they are likely not covered under your travel insurance plan.

Clarify and confirm your family is protected under your travel insurance plan and their amount of coverage.

High-risk activities

What are you doing during your holiday? Will you engage in any high-risk activities, like parasailing or deep-sea diving? If you intend to participate in anything where injury or fatality could occur, ask your insurance company if they include accidents resulting from these activities under your insurance coverage.

Your destination

Suppose you’re travelling to a destination where the Canadian government has issued an advisory against travelling there. In that case, your insurer may not be able to provide you with travel insurance coverage. Tell your insurer where you plan on travelling—especially if you’re making multiple stops in different countries.

Ask if coverage conditions will change in a situation where the advisory status worsens after purchasing your travel insurance.

Check the Canadian Government’s Travel Advice and Advisories website before planning your trip and again shortly before you leave. Be prepared for a travel insurance denial if you plan on travelling to any countries indicated as “Avoid all travel” on this website.

If travelling to a contentious location, ask your insurer about the limit or aggregate maximum payable for all those in your travel party covered by your insurance policy.

A person receiving a text message that their flight was cancelled due to COVID-19.

Just before you travel…

Here are a few final travel insurance preparations to make before you board that plane, train, or automobile:

  • Read your policy thoroughly before you leave. If you have any questions, clarify with your insurance provider until your understanding is crystal clear. Never assume anything about the conditions of your policy.
  • Document the emergency contact number for your travel insurance company on paper and make two copies. Put one copy in your luggage and always carry the other with you while you travel. Give the third copy to a friend or relative at home. Save this information on your mobile device.
  • Contact your insurer as soon as possible after receiving health care while abroad to inform them of what’s happened. Ask for detailed reports and invoices from the doctor or hospital that helped you (this can be challenging when you’ve returned home.) Make copies of your medical receipts but send the originals to your insurance provider.
TIP: Request a travel card.

Request a travel card from your travel insurance provider. It will include information on who to contact if you need to submit a claim.

A man upset over a refused travel insurance claim.

Top 5 reasons for denied travel insurance claims

It’s essential to be clear about your medical history and trip details; otherwise, you could face a denied claim.

These are the 5 top reasons for denied travel insurance claims:

  • Undisclosed pre-existing medical information. The insurer discovers missing medical information from your application, which the insurer determines is “material to the risk.” In other words, if the insurer had this information, they either wouldn’t have issued the policy or would have charged a higher premium. Also, the missing data doesn’t need to be related to the claim that the insurer is denying. The consequence is that the policy can be cancelled.
  • Pending medical tests. If your doctor has requested testing to investigate a possible medical condition and you haven’t concluded the testing and received your results by the start of your insurance coverage. Recall that the missing information doesn’t need to be related to the claim that the insurer is denying. 
  • Changes to your health before your trip. If your health condition changes before your insurance coverage start and you don’t inform your insurer of these changes, no matter how slight the difference may be.
  • Failure to notify your insurer about a claim. If you don’t inform your insurance provider of an incurred claim as soon as possible. In other words, if you go to the hospital or receive medical care in another country and don’t promptly inform your insurance provider about the incurred claim.
  • Submitting a claim too late. You try to submit a claim for a cost incurred after the coverage period because you extended your vacation and did not inform your insurance company. 

If your insurer has denied your travel insurance claim and you’ve unsuccessfully appealed the claim through their internal complaints process, you can submit a complaint to OLHI for an additional review:

See our Complaints process >>

What is an ombudsman? What is alternative dispute resolution (ADR)?

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Our Ombudsman is head of the OmbudService for Life and Health Insurance (OLHI). OLHI offers an alternative dispute resolution public service that is free, bilingual, independent and impartial to Canadians with life and health insurance.

Sounds great so far, right? But what is an ombudsman or an ombudservice? How does alternative dispute resolution (ADR) work?

More importantly, how can an ombudsman or ADR help you?

Ombudsman: A brief history

More than 200 years ago, Sweden appointed the first Ombudsman to resolve complex problems when the King was away. The term “ombudsman” originates from “ombuds” (umboðsmaðr), which means “proxy agent” or “representative” in Old Norse.

Today, there are ombudservice offices for governments, organizations, and financial institutions across the globe.

Did You Know?

Over 100 countries are members of the International Ombudsman Institute.

What does an Ombudsman do?

An ombudsman can review complaints from the public about government, organizations, or financial institutions. An ombudsman’s goal is to help both sides come to a resolution via mutual agreement.

A mediator helping a consumer and an insurance company representative come to an agreement.
An ombudsman’s goal is to help both sides come to a resolution via mutual agreement.

Canadian life and health insurance consumers can submit a complaint to us if they feel dissatisfied with their insurer’s final position on a policy.

See our Complaints process >>

If your complaint is reviewable, we can review your policy outcome. If it has merit, OLHI can offer a non-binding recommendation to your insurance company.

Note: an Ombudsman is impartial.

An ombudsman is impartial, so they don’t represent the consumer or the organization, which in the case of OLHI, helps build confidence in Canada’s life and health insurance sector.

According to the International Network of Financial Services Ombudsman Schemes, the hallmark of an ombudsman is a “free, independent, impartial, fair, timely, efficient and informal alternative dispute resolution process.” 

Alternative Dispute Resolution in a nutshell

At its core, Alternative Dispute Resolution (ADR) is about finding fair resolutions to disputes outside the courts.

In other words, say you have a complaint with your life or health insurance provider, ADR may help solve your problem without expensive, lengthy, and adversarial litigation.

Benefits of Alternative Dispute Resolution (ADR)

Consider the benefits of ADR; you may thank yourself later. Alternative Dispute Resolution is:

  • Confidential—ombudservices have strict privacy policies and cannot share your information with anyone
  • Far more flexible than court proceedings
  • More cost-effective than litigation—it’s a free service to the public
  • Can offer resolution faster than litigation
  • Applicable over multiple jurisdictions (e.g., provinces, countries) at once, thereby evading a substantial time commitment to several lawsuits

How can an Ombudsman help me?

The OmbudService for Life and Health Insurance (OLHI) provides an impartial, independent, bilingual, and free ADR public service to the 29 million Canadians with life and health insurance.

Our public service can also guide consumers through the complaints process and answer their questions. We can also help them find lost policies or policies of deceased loved ones.

How we can help >>

The Anatomy of a Final Position Letter: What to Expect From Your Life or Health Insurance Provider

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A final position letter is a written decision from a life or health insurance company that outlines its final position about a consumer claim.

Here’s what you can expect to see in a final position letter ↓

The anatomy of a final position letter
View the full image >>

All insurance companies have an internal complaints process, which you must follow to obtain a Final Position Letter from your insurer before you bring your complaint to us at the OmbudService for Life and Health Insurance (OLHI).

Once you have received a Final Position Letter, you can submit your complaint to us.

Got your Final Position Letter? Here’s the next step:

Once you have received a Final Position Letter from your life or health insurance provider, you can submit a complaint to our ombudservice.

If your complaint is reviewable and has merit, we can provide another impartial review of your insurer’s final position on a health or life insurance claim.

Take a few minutes to learn more about our complaints process so you know what to expect:

See the full complaints process >>

How to find if a life insurance policy exists for a deceased person

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If you are responsible for closing out a deceased loved one’s financial concerns, one of your tasks might be to find out if a life insurance policy exists for them.

Estate planning can be complicated and time-consuming. In some cases, individuals get all their affairs in order before they pass on. But, in the event of an unexpected death, family and loved ones may need to take a more active role in managing the deceased’s estate. This includes financial matters, like life insurance. 

Locating the deceased’s life insurance policy

When you are managing a deceased’s financial matters, you may find everything you need in a filing cabinet or on their computer. This is not always the case, and it can take a lot of time to locate all relevant paperwork.

If you know your loved one had a life insurance policy, here is a list of where to look:

Where to search for a lost life insurance policy of a deceased

  • To find if a life insurance policy exists for a deceased person, start with possible storage places, like safety deposit boxes or filing cabinets.
  • Go through the deceased’s papers, checking for policies, statements or notices from an insurance company. 
  • Review banking records for any evidence of premium payments. 
  • Contact the deceased’s insurance agent (if known) and other advisors, like lawyers and accountants. Sometimes, policies are stored in their files. 
  • Contact the deceased’s employer, or former employer if the deceased was retired. The Human Resources Department would have information on group life insurance for active or retired employees. 
  • If the deceased was receiving group disability benefits, find out if there was any group life insurance included.
  • Contact any associations to which the deceased belonged. Many offer members life insurance. For example, lawyers, accountants, construction workers, teachers, government employees or engineers belong to associations. 
  • Check with credit card companies to see if the deceased purchased any life or travel insurance through the card. 
  • If the deceased passed away while travelling, check whether special insurance was purchased for the trip. Sometimes, travel insurance provides a death benefit. 
A frustrated woman looking for a lost insurance policy.
We’re here for you if you believe your loved one had a life insurance policy but can’t find it.

What to do if you can’t find the policy

Sometimes there really is no paper trail or email about the deceased’s life insurance policy. If you cannot find the policy, OLHI may be able to do the search on your behalf by contacting our member companies to see if they hold the policy.

This link explains our policy search process, including:

  • How OLHI’s search works 
  • When we can and cannot do a search 
  • How to submit a search request to OLHI 
Start a search >>

Ask for help when you need it

Losing a loved one is never easy. It can be even harder if you’re managing the deceased’s affairs. Make sure you ask for emotional support when you need it and take the time you need to grieve in your own way.  

Helping Canadians find a life insurance policy for a deceased loved one is an important part of our public service. We’re here for you if you believe your loved one had a life insurance policy but you can’t find it.

Contact us >>

What happens if a life or health insurance company denies your claim?

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Did you know that you can make a complaint if your life or health insurance company denies your claim?

Before you submit your complaint to us at the OmbudService for Life and Health Insurance (OLHI), you first need to go through your insurance company’s internal complaint process. 

Can I go directly to OLHI with my denied insurance claim?

OLHI can’t review a complaint about a denied claim if you haven’t gone through your insurer’s internal process.

We’ll know that you completed this process if you have a “final position letter”—it’s one of the first things we’ll ask for after you submit a complaint to OLHI.

How to submit a complaint to your life or health insurance company

1. Appeal your denied claim.

If your life or health insurance claim gets denied, a Case Manager will send you a claim denial letter. Each submitted claim gets assigned to a Case Manager, whose job is to review these claims to see if they are payable—or not.

An example of claim denial letter from a life or health insurance company.
A claim denial letter will provide step-by-step instructions on how to appeal your denied claim.

A claim denial letter will provide step-by-step instructions on how to appeal your denied claim. You’ll likely need to provide additional details (in writing) to your insurer to clarify the context of your claim.

If you receive a second claim denial letter, now you have the grounds to file a complaint.

Tip: Be calm and polite.

Trying to resolve a complaint can be frustrating and stressful. Our experience is that a courteous manner leads to an easier and faster resolution.

2. Submit your life or health insurance complaint to a Complaint Officer.

Once you’ve unsuccessfully appealed your denied claim, you can escalate your situation to a Complaint Officer at your insurance company.

A Complaint Officer has the authority to make a final decision about your complaint.

A man calling his insurance company.
Before sending your complaint, contact your insurance company to determine to whom you should address your complaint and what documentation you need to attach.

Tip: Submit your complaint in writing.

It’s usually best to send your complaint in writing. Many insurance companies will have an email address or online form you can use to make your complaint. You may also be able to send it by mail.

Before sending your complaint, contact your insurance company to determine to whom you should address your complaint and what documentation you need to attach.

OLHI has a Consumer Complaint Officer Listing tool that allows you to quickly find the contact information for your insurance company’s Complaints Officer. (If you don’t see your insurance company on this list, it means they aren’t a member company of OLHI.)

Tip: How to format your written insurance complaint

• Put “Complaint” at the top of your letter or in the subject of your email.

• Be clear about what went wrong and when.  

• Tell your insurance company what you expect as a solution.

3. Submit your life or health insurance complaint to a Complaint Officer.

Once you complete your insurance company’s complaint process, you will receive a “final position letter.” If you don’t receive a final position letter, ask for one from the Complaint Officer.

A final position letter with further detail on its contents—date, reference number, context, and the insurer's review process and final position.
If you don’t receive a final position letter, ask for one from the Complaint Officer.

4. Contact OLHI if you haven’t heard from your Complaint Officer in 90 days or more. 

If your insurer takes longer than 90 days to reach a decision, ask OLHI to contact your company to inquire about the status of your complaint.

Contact us >>

What to do if you’re unhappy with your insurer’s final decision on your complaint

Followed all the steps above, but you’re still dissatisfied with your insurer’s final position? You can now submit a complaint to OLHI. If your case is reviewable and has merit, we can provide a free, independent, and impartial review.

Learn more >>

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